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University  of 
California 
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UNIVERSIT  SAN  DIEGO 

DATE  DUE 


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ON 


THE    CONGENITAL    MALFORMATIONS 


OF    THE 


RECTUM    AND   ANUS. 


\ 


Plate  1. 


Vide     Case     CX.  I;.p.  ?47. 


A     r  R  A  C  T  I  C  A  L     T  II  E  A  T  1  S  E 


ON   THE 


.ETIOLOGY,  PATHOLOGY,  AND  TREATMENT 


OF   TIIH 


CONGENITAL     MALFORMATIONS 


OF   THE 


RECTUM  AND  ANUS. 


BY 
WILLIAM    BODENIIAMER,   M.  D. 


"  Necessitas  medicinam  invenit,  experientia  perfecit." Hippocratks. 

"  By  .studying  Nature  in  her  Imperfections  and  Irregularities,  we  are  more  likely  to 
arrive  at  some  Knowledge  of  her  Laws,  than  if  we  regard  her  only  in  her  Healthy  con- 
dition."  Ramsbotham. 


Illustrated  by  XVI  Plates  and  Exemplified  by  CCLXXXVII  Cases. 

NEW   YOEK: 
SAMUEL  S.  &  WILLIAM  WOOD,  389  BROADWAY. 


mdccClx. 


Entered,  according  to  Act  of  Congress,  in  the  year  one  thousand  eight  hundred  and  sixty, 

Bt    WILLIAM    BODENHAMER, 

In  the  Clerk's  Office  of  the  District  Court  of  the  United  States  for  the  Southern  District 

of  New  York. 


J.    H. 

TOBITT, 

COMBIXATIOK 

-TTPE      PBINTEK,     j 

1  Franklin 

Square,  iV. 

r. 

TO 

WILLIAM     HUSTON     BODENHAMER, 

iSow    A    Student 
At  L^ Ecole-De-Medic'ine  of  Pakis, 

THIS    WO  RK 

IS 

Most    Respectfully   and    Affectionately 

INSCRIBED 

Ir 

By     his     Father, 

THE  AUTHOR. 


r»  R  E  F  A^  C  E 


Whatever,  may  be  said  with  regard  t:)  either  the  merits  or  the 
demerits  of  this  wort,  all  will  admit  that  the  subject  of  it  is  of  the 
highest  importance,  and  that  such  a  production  as  is  hero  aimed  at, 
is  decidedly  a  desideratum  in  surgical  literature.  The  utility  of 
oUch  a  treatise  is  undoubted,  and  will  not  be  called  in  question. 

No  complete,  systematic  or  practical  work  on  the  congenital  mal- 
formations of  the  rectum  and  anus,  has  ever  been  published  in  this 
or  any  other  country.  The  literature  on  this  subject  lies  buried  in 
undigested  confusion  in  the  various  channels  throughout  the  range 
of  the  science — hence  it  can  only  be  found  in  brief  and  detached 
articles  and  memoirs  as  presented  in  the  transactions  of  societius  ; 
in  some  of  the  special  treatises  on  the  diseases  of  the  rectum  and 
anus  ;  in  the  systematic  works  on  surgery  ;  in  the  dictionaries  ;  or  in 
the  various  periodicals  of  the  day.  The  voluminous  and  the  expen- 
sive character  of  most  of  these  works,  containing  articles  on  this 
subject  ;  their  scarcity  and  the  difficulty  of  obtaining  them,  as  well 
as  the  largest  number  of  them  being  clothed  in  a  foreign  language, 
render  them  in  a  great  degree  inaccessible  to  the  largest  majority 
of  practitioners. 

To  remedy  this  serious  evil  and  to  fill  this  void,  the  author  has  in 
the  present  work  endeavored  to  collect  these  scattered  materials 
into  one  continuous  whole,  adding  to  them  his  own  reflections  and 
experience  on  the  subject;  and  thus  presenting  in  a  systematic  and 
coniuH-tcd  fi;rni,  a  complete  and  accurate  exposition  of  the  cougeni 


vi  Preface. 

tal  malformations  of  the  rectum  and  anus,  their  aetiology,  pathology, 
classification  and  treatment. 

Notwithstanding  several  very  able  and  highly  valuable  contribu- 
tions on  this  subject  have  been  made  within  the  last  half  century, 
nothing  like  a  general  treatise  has  been  attempted.  Of  the  princi- 
pal contributors  to  this  literature  in  later  years,  the  names  of  Ben- 
jamin Bell,  Thomas  Copeland,  and  A.  Copeland  Hutchison  of  Eng- 
land;  MM.  Amussat  and  Roux  de  Brignoles  of  France  ;  Von  Ani- 
mon  and  Friedberg  of  Germany ;  and  Dr.  Bushe,  Dr.  Barton  and 
Dr.  Gray  of  the  United  States,  may  be  mentioned  as  the  most  im- 
portant. "  Th".  Boston  Society  for  Medical  Lnprovement  "  has 
within  the  last  few  years  highly  distinguished  itself  by  investigating 
this  subject  quite  thoroughly,  and  Dr.  Gay,  already  named,  one  of 
its  able  members,  has  produced  a  valuable  paper  on  it.  It  is,  how- 
ever, more  especially  to  the  genius  and  master  pen  of  M.  Amussat 
of  France  that  we  are  indebted  for  having  drawn  from  oblivion  as 
it  were,  this  long  neglected  and  forgotten  subject,  and  for  restoring 
it  to  that  rank  to  which  it  is  entitled. 

Although  these  eminent  surgeons  have  by  their  able  productions 
inaugurated  a  new  surgical  epoch  with  regard  to  the  anatomy,  the 
physiology  and  the  treatment  of  these  congenital  vices  of  conforma- 
tion, yet  it  is  surprising  the  little  advancement  which  is  being  made 
on  the  subject.  A  congenital  imperforation  of  the  anus  and  rectum 
is  still  regarded  by  many  surgeons  merely  as  an  anatomical  lusus 
naturcB,  beyond  the  power  of  art  to  remedy,  and  is  still  to  a  great 
extent  the  opprobrium  medicum. 

The  investigation  of  these  abnormal  conditions  of  the  rectum  and 
anus  is  invested  with  a  deep  interest,  not  only  as  an  important  pa- 
thological inquiry,  but  above  all  as  conducive  to  the  adoption  of 
measures  calculated  to  be  highly  beneficial  to  a  class  of  little  suffer- 
ers, the  most  unfortunate  and  deplorable.  The  subject  is  a  very  im- 
portant one,  and  is  presented  not  for  the  benefit  merely  of  the  curious, 
in  anatomical  pursuits,  but  on  account  of  its  practical  relations,  and 
for  the  ultimate  and  permanent  good  of  the  little  sufierers  themselves  ; 
consequently  it  presents  itself  to  the  humane  surgeon  as  an  object 
demanding  his  most  deliberate  and  serious  attention,  for  among  the 


PREFACE.  VI 1 

many  forms  of  death  which  surround  the  cradle  and  which  are  the  ob- 
jects of  parental  care  and  solicitude,  those  which  depend  upon  a 
malformation,  or  an  imperfect  state  of  tlic  excretory  passages,  an' 
perhaps  the  most  distressing  in  their  nature  and  make  the  most  pain- 
ful impressions  upon  the  minds  of  the  parents. 

In  the  elucidation  of  this  subject,  the  author  disclaims  all  preten- 
tious to  an  extensive  practical  and  personal  knowledge  of  it ;  indeed 
this  seldom  falls  to  the  lot  of  any  one  practitioner,  however  exten- 
sive his  practice  may  be. 

It  may  be  alleged  that  in  treating  this  subject,  the  author  has 
been  guilty  of  great  repetition  and  prolixity,  but  as  the  subject  is 
so  importaut,  and  has  been  so  little  discussed,  he  thought  it  might 
prove  benedcial  to  enter  into  it  somewhat  in  detail. 

Whether  this  work  will  prove  to  be  valuable  or  not,  it  has  been 
the  result  of  much  reflection  and  long  labour,  and  the  author  claims 
for  it  entire  originality  in  the  general  design  and  treatment  of  tho 
subject.  The  extent  of  his  researches  will  be  understood  when  it 
is  known  that  he  has  consulted  and  cited  the  large  number  of 
authorities. presented  in  the  Bibliography  at  the  commencement  of 
the  Introduction.  This  extensive  Bibliographical  Index  forms  of  itself 
a  complete  history  of  these  congenital  vices,  and  will  greatly  facili- 
tate the  study  of  them. 

In  this  work  the  practitioner  will  find  reported  nearly 
three  hundred  cases,  collected  from  the  numerous  sources, 
being  by  far' the  largest  number  ever  presented  in  any  one 
sino-le  production  on  the  subject.  The  record  of  these  cases  will 
show  their  singular  variety  ;  they  have  all  been  carefully  classed 
according  to  their  species,  and  most  all  of  them  have  been  reported 
in  full,  and  as  near  as  could  be,  in  the  precise  language  of  their 
authors.  Many  of  these  reports  have  been  translated  from  the 
French,  the  German,  and  the  Latin,  especially  for  this  work.  The 
author  has  made  but  few  remarks  in  relation  to  any  of  them,  pre- 
ferring to  present  in  full  the  instances  themselves,  as  facts,  from 
which  each  practitioner  might  form  his  own  opinion,  and  draw  his 
own  conclusions.  It  will  be  seen  that  the  observations  of  authors 
and   the  cases,    have    been   generally   collected   from  the   original 


Vlll  PREFACE. 

sources,  instead  of,  as  is  often  the  case,  from  the  mere  references 
made  to  them  by  others. 

It  is  a  singular  fact,  and  not  unworthy  of  observation,  that  in 
reading  the  French  authors  on  these  congenital  deformities,  one 
will  be  strongly  impressed  with  the  idea  that  beyond  the  bound- 
aries of  France  nothing  whatever  is  known  on  the  subject.  The 
same  may  be  said  with  respect  to  the  Germans.  In  their  produc- 
tions on  these  congenital  vices,  they  scarcely  ever,  if  at  all,  allude 
to  the  French  or  the  English  ;  and  neither  the  French,  the  Germans, 
nor  the  English  ever  refer  to  any  American  authority  in  relation  to 
them.  Whether  this  should  be  attributed  to  ignorance  of  the  gen- 
eral literature  of  the  subject,  or  to  national  pride  or  prejudice,  the 
author  will  not  attempt  to  determine.  In  the  following  pages,  how- 
ever, he  has  brought  together  in  one  harmonious  body,  for  the  mu- 
tual benefit  of  the  whole,  authorities,  both  English,  French,  Ger- 
man and  American. 

This  work  will  contain  both  the  medical  and  the  surgical  treat- 
ment in  full  from  the  earliest  times,  with  all  the  improvements, 
down  to  the  present  day.  The  last  chapter  will  give  a  complete 
exposition  of  the  highly  interesting  subject  of  Abdominal  Artificial 
Anus,  so  far  as  it  relates  to  new-born  children. 

The  simple  Classification  which  has  been  adopted,  the  careful 
arrangement  of  all  the  cases  under  their  appropriate  heads,  the 
Alphabetical  Index  to  these  cases  at  the  end  of  the  work,  and  the 
numerous  LithograpJdc  Ilhist rations,  will,  it  is  hoped,  be  found 
highly  convenient  and  useful. 

In  conclusion  the  author  humbly  submits  this  treatise  to  the  pro- 
fession with  all  its  imperfections,  hoping  that  it  will  supply  a  hiatus 
in  the  resources  of  the  surgical  art. 

854  Broadway,  New  York,  ) 
September,  ISGO.      | 


T^BLE    OF    COISTTENTS. 


CHAPTER  I. 

INTRODUCTION. 

SECTION  I. 

PAGE. 

Bibliography,       --  ______        17 — 3G 

SECTION  II. 

General  Remarks. — The  Rectum  and  Anus  liable  to  congenital 
malformations  and  niiperl'ections — The  congenital  closure  of  the 
anus  noticed  from  the  remotest  antiquity  by  the  Greek,  Roman  and 
Arabic  physicians — The  tenns  used  to  designate  these  vices  of  con- 
formation— The  importance  of  examining  minutely  every  infant 
immediately  after  birth— The  pernicious  practice  of  purging  new- 
born children,  irrespective  of  circumstances — These  malformations 
considered  quite  uncommon  by  some  surgeons — The  author  differs 
from  this  opinion — The  impossibility  of  arriving  at  satisfactory 
conclusions  on  the  subject  from  the  very  meager  data  furnished,  37 — 41 

SECTION    III. 

Etiology. — Nothing  satisfactory  has  yet  been  ascertained  with  re- 
gard to  the  primary  cause  which  determines  these  congenital  im- 
perfections of  structure — What  the  science  of  embryology  teaches 
on  the  subject — The  herculean  labors  and  the  theories  of  the  dis- 
tinguislied  and  celebrated  organologists  MM.  (Saint-Hilaire, 
Serres,  Meckel,  Tiedmann,  Andral,  &c.,  noticed — Some  of  these 
malformations  are  the  result  of  disease  in  intra-uterine  life — 
Instances  given  to  prove  this — What  influence  does  sex  exercise 
in  the  production  of  defective  congenital  developments,         -         41 — 46 

SECTION  IV. 

Anatomical  and  Pathalogical  Characters. — These  congenital 
malformations  present  a  great  variety  of  forms  from  the  most  sim- 
ple to  the  most  complex  —The  anatomical  and  the  pathological  con- 
ditions which  constitute  these  defective  developments,  considered 
separately — The  historj'  of  the  development  of  the  rectum  and  the 
anus,  given — The  manner  in  which  many  of  these  malformations 
occur — Synopsis  of  the  congenital  malformations  of  the  anus  and 
the  rectum,         --  ...._-        4G — 51 

is. 


TABLE    OF   CONTENTS. 


SECTION  V. 


PACE. 


Classification. — The  anatomical  and  the  patliological  condition  of 
these  congenite  vices  of  structure,  taken  as  the  basis  of  classifica- 
tion— They  are,  for  practical  purposes  merely,  distinguished  into 
nine  species — In  this  arrangement,  convenience  is  considered, 
rather  than  a  show  of  scientific  precision— The  description  of  each 
species,        ___-__----         52 — 5 -J 

SECTION  VI. 

General  Symptoms. — The  existence  of  these  congenital  malfor- 
mations manifests  itself,  in  the  majority  of  instances,  bj'  a  train 
of  morbid  phenomena,  simulating  strangulated  hernia,  the  result 
of  the  retention  of  meconium  and  other  matter — If  not  relieved, 
death  generally  takes  place  between  the  third  and  eighth  day, 
according  to  the  vigor  of  the  little  patient — When  protracted 
beyond  this  period  its  life  is  purely  vegetative,  there  is  extreme 
emaciation,  and  death  results  from  the  eifects  of  inanition — 
Instances  given  in  which  children  have  lived  a  niunber  of  days, 
and  even  months,  without  any  passage  from  their  bowels — 
When  death  takes  place,  it  is  most  usually  the  result  of  enteritis, 
peritonitis  and  intestinal  paralysis — The  appearances  after  death — 
The  pathognomonic  sign  obtained  by  the  direct  inspection  of  the 
anus  and  rectum,         ----____         54 — 57 

section     VII. 

Prognosis. — These  malformations,  as  well  as  those  of  the  genito- 
urinary organs,  were  looked  upon  anciently  as  necessarilj^  fatal, 
and  the  unfortunate  victims  of  them,  regarded  in  the  light  of 
monsters — These  sentiments,  even  at  the  present  day,  prevail  to 
a  certain  extent — ^lany  surgeons  abandon  nearly  all  such  cases, 
believing  them  to  be  bej^ond  the  power  of  art  to  remedy — This 
is  a  grave  error,  which  will  be  shown  hereafter — From  the  great 
improvements  that  have  been,  and  are  being  made  in  modern  sur- 
gery, the  evil  is  by  no  means  deplorable,  even  in  some  of  the 
most  desperate  cases,  as  will  be  shown — The  most  formidable 
cases  are  those  in  which  there  is  considerable  deficiency,  or  an 
entire  absence  of  the  rectum,  and  in  which  no  outlet  whatever 
exists — Even  such  cases  can  now  generally  be  saved,  eitlier  by  the 
operation  oi  Proctoplasty  or  Colotomy—^o  case  should  be  abandon- 
ed in  despair — A  doubtful  remedj^  even,  should  be  preferred  and 
attempted  in  preference  I0  the  certain  death  of  the  child — It  is  an 
important  fact,  that  cliildren  sustain  an  operation  much  better 
immediatel}- after  birth,  than  at  a  later  period,     -        -        _         57 (jj 

CHAPTER  II. 

THE  FIRST  SPECIES  OF  MALFORJIATIOX. 

SECTION    I. 

Description. — This  species  of  congenital  malformation  is  character- 
ized by  an  abnormal  narrowing  of  the  anal  orifice — This  narrow- 
ing may  present  all  the  different  degrees  of  stricture,  from  that 
into  which  the  point  of  the  smallest  probe  cannot  be  introduced, 
and  impossible  for  the  meconium  to  pass,  to  that  which  opposes 


TABLE   OF    CONTKNTS.  XI 

PACK. 

no  obstruction  to  the  common  size  probe,  and  but  little  to  the 
passage  of  the  mecoiiiinii — The  contraction  may  be  organic,  and 
the  result  of  previous  iniliunmation,  or  it  may  be  spasmodic — Tlie 
situation  and  the  form  of  the  anus  in  this  species— The  signs  by 
which  it  maybe  recognized — The  syphilitic  variety  of  this  species 
of  congenital  narrowing,  and  the  signs  by  which  it  may  be  dis- 
tinguished,         -       -       01— <j;i 

SECTION  II. 

Till'.  Treatment. — The  treatment  is  by  dilatation  alone  ;  or,  by  incis- 
ion and  dilatation  combined,  according  to  the  straightness  of  the 
contraction — The  dilatation  must  be  ctfected  by  means  of  the  wax, 
gum-elastic,  or  metallic  bougies — The  wax  bougie  the  best — The 
measures  to  be  adopted  if  the  process  of  dilatation  should  excite 
undue  irritation  or  inflammation — The  importance  of  early  treating 
even  the  slightest  cases  of  this  species,  in  order  to  prevent  the 
evil  consequences  which  may  result  from  such  neglect,  in  the 
after-life  of  the  little  patient — Two  interesting  cases  are  related 
by  M.  Boyer,  in  which  the  contz-action  of  the  anus  was  overlooked, 
or  neglected  in  infancy,       .__----        C3 — 08 

SECTION  III. 

Cases  AND  Kemarks,       -------  G8 — /4 

CHAPTER  III. 
THE   SECOND   SPECIES   OF   MALFORMATION. 

SECTION    I. 

Description. — This  species  of  congenital  malformation,  atresia  ori- 
ficii  am,  is  characterized  by.  the  closure  of  the  anal  orifice,  by  a 
thin  transparent  membrane,  somewhat  resembling  the  hymen  ;  or, 
b}^  a  cutano-mucous  lamina,  sometimes  quite  thick  and  hard,  and 
simulating  the  common  integument  of  the  anal  region — The  signs 
by  which  it  is  distinguished — It  is  the  most  simple  form  of 
arrested  development  pertaining  to  the  anus,  and  doubtless  the 
most  common,     ---------        75 — H) 

section  II. 

The  Treatment. — The  treatment  of  this  species  is  simple,  and  if 
timely  adopted,  generally  successful — It  consists  of  a  puncture 
and  a  crucial  incision — The  method  of  operating  and  the  after 
treatment — There  is  in  these  cases  but  little  disposition  in  the 
newly  formed  anus  to  contract,  especially  if  the  occluding  mem- 
brane has  been  thin,  and  the  anus  well  formed,  as  is  usually  the 
case — The  advice  of  Professors  Hays  and  Pancoast,  of  Philadelphia 
— M.  Levret  recommended  a  circular  incision  in  these  instances,  7Cj—77 

SECTION  III. 

Cases  AND  Remarks,  -__.---        78  —  87 


Xll  TABLE   OF    CONTENTS. 

CHAPTER    IV. 
THE  THIRD  SPECIES  OF  MALFORMATION. 

SECTION  I.  PACE 

Description. — The  atresia  ani  et  intestini  recti,  is  a  species  of 
arrested  development,  in  which  the  I'cctum  docs  not  descend  as 
low  in  the  pelvis  as  it  should  do,  but  terminates  abruptly  in  a 
form  of  cul-de-sac  at  a  variable  distance  above  its  natural  outlet — 
No  anus  exists,  and  there  is  generally  not  even  the  trace  of  an 
anus  to  be  observed  in  aitu  naturali — This  is  truly  a  deplorable 
form  of  congenital  imperfection,  especially  should  a  considerable 
portion  of  tlie  inferior  extremitj^  of  the  rectum  be  deficient,     -     88 — 89 

SECTION  II. 

Physical  Exploration — Diagnosis. — It  is  of  the  highest  import- 
ance, in  these  cases,  in  which  there  are  no  external  signs,  to  make 
a  careful  and  minute  exploration — The  manner  of  conducting  this 
— Auscultation  and  percussion — The  introduction  of  the  sound 
into  the  bladder,  or  into  the  vagina.  The  small  excrescences  or 
elevations  of  the  skin,  which  are  sometimes  observed  in  these 
cases  at  the  normal  situation  of  the  anus — Their  deceptive  char- 
acter, with  regard  to  their  having  any  communication  with  the 
rectum.  The  place  of  the  absent  anus  is  sometimes  the  seat  of  a 
.small  depression,  pit,  or  a  fissure  or  fissures  of  the  skin,        -        89 — 91 

SECTION  III. 

Prognosis. — The  prognosis  unfavorable,  but  by  no  means  hopelessly 
so — A  very  fixvorable  issue  of  the  success  of  the  operation  in  any 
of  these  cases  must  not  be  too  confidentl}^  prognosticated — The 
difficulties  and  the  dangers  of  maintaining  the  newly  formed  canal 
patulous,  after  the  ordinary  operation,  as  enumerated  by  Bell,  Vel- 
peau  and  others,  are  by  no  means  exaggerated  or  imaginary — Con- 
siderations which  induce  many  surgeons  to  repudiate  all  treat- 
ment in  such  cases — The  opinion  of  Professor  J.  H.  Bigelow,  of 
Harvard  University,  on  this  subject — The  highlj'  encouraging  re- 
sults in  a  number  of  these  cases  reported,  authorise  and  warrant 
an  attempt  at  relief  by  some  operation.  MM.  Amussat,  Roux  de 
Brignales  and  Goyraud,  of  France,  in  1835,  were  of  opinion  that 
all  such  cases,  previous  to  that  time,  were  never  successfully 
treated,  if  treated  at  all — They  claimed  the  credit  of  introducing 
free  incisions  in  the  perinajum  with  the  scalpel,  guided  by  the 
finger,  in  search  of  the  blind  end  of  the  rectum.  Benjamin  Bell 
and  A.  C.  Hutchison,  of  England,  and  Dr.  Campbell,  of  America, 
are  proved  to  have  successfully  operated  by  this  method,  on  just 
such  cases,  many  years  previous,  -        -        -        _         _        gj yg 

SECTION  IV. 

The  Treat.ment. — That  treatment  which  holds  out  the  greatest 
prospect  of  success  in  these  cases,  is  that  which  contemplates  the 
establishment  of  an  artificial  anus  in  the  perina3um,  Proctoplaktu — 
Description  of  this  operation — When  should  the  operation  be  un- 
dertaken?— Theadvico  of  Hutchison  and  Dieffenbach  on  the  sub- 
ject— The  infant  pelvis — Ilie  admeasurements  of  it  in  two  cases — 
The  introduction  of  the  sound  into  the  urethra  of  the  male,  or  into 


TABLE    OF   CONTKNTS.  XI II 

pa(;k. 
tlie  vagina  of  tlie  fouiale — The  form  of  incision— Tlic  loiif:;itii(linaI 
incision — Tlie  transverse  incision — The  crucial  incision — The  T- 
incision — The  sphinctores  ani  muscles.  The  coniiicting  opinion  of 
authors  with  regard  to  their  invariable  presence  or  absence  in 
these  cases — The  rectum  in  these  instances  is  not  only  malformed, 
but  may  occujiy  an  abnormal  position  in  the  pelvis — The  nu;thod 
of  operating  recommended  by  the  author — The  ordinary  method 
of  operating — The  liability  of  the  newly  made  passage  to  coarcta- 
tion— The  opinions  of  Bell,  Yelpeau,  Dionis  and  Malyn,  on  the 
sulijcct — The  objections  of  jNI.  Amussat  to  the  ordinary  method 
of  operation — Some  of  his  objections  shown  to  be  untenable — The 
method  of  M.  Amussat — Its  merits  and  demerits  considered — 
The  operation  of  Amussat  recommended  and  performed  by  others 
— x\mussat  abandons  his  beautiful  operation  in  these  cases,  and 
now  performs  colotomy  instead — The  operation  by  puncture — 
'llie  great  danger  and  uncertainty,  in  these  cases  attending  the 
"  hl'md  ■plunge''''  of  a  piercing  instrument — Perinaeal  puncture,  at 
this  day,  shoidd  be  abandoned  in  these  cases — The  modification 
of  the  operation  by  puncture,  as  practiced  by  Bell,  Hutchison  and 
Dieflenbach — What  to  be  done  in  case  of  the  failure  to  form  a 
perina3al  artificial  anus,      -------         9G — 123 

SECTION  V. 

Oases  AND  Remarks,  _______        123—161 

CHAPTER    V. 
THE  FOURTH  SPECIES  OF  MALFORMATION. 

SECTION    I. 

Description. — In  this  species  of  congenital  malformation  the  anus 
is  usually  quite  normal,  whilst  the  rectum  at  a  variable  distance 
above  it,  is  either  obliterated,  partially  or  wholly  absent,  or  oc- 
cluded by  a  thin  or  a  thick  annular  membranous  septum  like  a 
diaphragm — The  ano-rectal  septum  sometimes  thick,  and  the  con- 
sistence of  horn — A  well-formed  anus,  no  evidence  that  the 
rectum  above  it  is  normal — This  species  presents  a  form  well  cal- 
culated to  deceive  the  most  experienced — The  importance  of 
making  a  visual  and  tactile  examination  of  the  anal  region  of 
every  child  which  fails  to  pass  meconium  within  the  first  twelve 
hours  after  birth — The  speculum  ani  can  be  used  iu  these  cases  to 
great  advantage — The  prognosis,       -----        162 — 165 

section    II. 

The  Treatment. — The  method  of  opei*ating  in  those  cases — The 
peculiar  method  of  M.  Amussat,       -----         165 — 167 

section    III. 

Cases  and  Remarks,  __--__        167 — 199 

CHAPTER  VI. 
THE   FIFTH   SPECIES  OF  MALFORMATION. 

SECTION    I. 

Description. — In  this  species  of  malformation  the  rectum  near 
its  inferior  extremity  sends  off  a  pipe-like  prolongation,  which 


XIV  TABLE   OF   CONTENTS. 


PAGE. 


terminates  externally  in  a  preternatural  orifice  at  some  point  in 
the  perinajum,  or  at  various  points  beneath  the  urethra;  at  the 
labia  pudendi,  or  at  some  point  in  the  sacral  region — These  ad- 
ventitious canals  resemble  very  much  the  ordinar}'  fistulous  pas- 
sages— This  species  has  been  included  in  that  which  Papendorf 
denominates  "  Atresia  Ani  Vesicalis — Urethralis — Vaginalis''' — 
This  arrangement  improper  for  reasons  given — The  prognosis  is 
generaUy  favorable,  - -        200—202 

SECTION    II. 

The  Treatment. — The  indications  to  be  observed — The  treatment 
in  the  male  subject — The  process  of  Dieffenbach — The  process  of 
Friedberg — The  treatment  when  the  rectum  terminates  in  an 
abnormal  opening  at  the  labia  pudendi,  the  vulva,  &c. — The  pro- 
cess of  Vicq  D'Azjr, 202— 20G 

section  iii. 
Cases  and  Remarks,  ._____-        206 — 224 

CHAPTER    YII. 
THE  SIXTH  SPECIES   OF  MALFORMATION. 

SECTION  I. 

Description. — In  this  species  the  rectum  terminates  by  an  abnor- 
nal  anus,  either  in  the  bladder,  the  urethra,  the  vagina,  the 
uterus,  or  in  a  cloaca  in  the  perinaeum  with  the  urethra  and  the 
vagina — Generally  no  normal  anus  exists — This  preternatural 
alliance  of  the  digestive,  the  urinal  and  the  generative  .systems  is 
analogous  to  the  normal  formation  of  some  animals — This  division 
of  the  congenital  malformations  of  the  anus  and  rectum  is  the 
"  Cloaca  Congenita'''  of  Meckel,  and  the  "  Atresia  Ani  Vesicalis, 
Urethralis  and  Vaginalis  "  of  Vixpendovt — The  manner  in  which  the 
rectum  communicates  with  the  genito-uriuary  passages — Physical 
signs  and  diagnosis — The  prognosis  in  each  variety  of  this  species,  225-231 

section  ir. 

The  Treatment. — The  indications  in  the  treatment  of  the  various 
varieties  of  this  species — The  treatment  when  the  rectal  open- 
ing is  either  vesical  or  urethral,  in  the  male — The  proceeding 
©f  Amussat  in  such  cases — The  proceeding  of  IMartin — The  treat- 
ment when  the  rectum  opens  in  the  vagina — Two  very  distinct 
methods  of  operation  proposed,  with  very  ingenious  modifications 
— The  method  of  Vicq  D'Azyr — Modifications  of  it  by  Martin 
and  Velpeau — The  method  of  Barton — Dieffenbach  proposes  two 
methods,  _.---..-_        231—235 

section  III. 

Cases  and  Remarks,  - 236 — 277 

CHAPTER   VIII. 

THE  SEVENTH  SPECIES  OF  MALFORxMATION. 
section    I. 

Description. — In  this  singular  species  of  malformation,  the  ureters, 
the  vagina  or  the  uterus  may  terminate  in  tlie  rectum  by  an  ab- 
normal orifice — IIow  the  ureters  tenuinate  in  the  rectum — How 


TABLE   or    CONTENTS.  XV 


I' AUK. 
the  vaii'ma  or  tlic  uterus  ti'ruiinates  in  the  rectum — In  these 
cases  tlie  menstrual  evacuation  passes  by  the  anus —  I'he  possibility 
in  such  cases  iif  impregnation  taking  place  by  coitus  jJcr  (luiim, 
and  even  parturition  per  ndum  safely  ellected — The  celebrated 
Thesis  of  M.  Louis  on  this  subject — Ihe  presentation  of  this  thesis 
causes  him  to  be  prosecuted  by  the  Parliament  of  Paris  ;  and  the 
Doctors  of  the  Sorbonnc  interdict  him — The  Pope  grants  him 
absolution — His  Thesis  published  in  1754,         -         -         _         278 — 279 

SECTION   II. 

The  Treatment. — Surgery  seems  altogether  out  of  the  question  in 

some,  ifuot  all,  of  these  cases,  .         .         -         -         -         279 — 280 

section  iii. 
Cases  and  Remarks,  __._-__        280 — 282 

CHAPTER    IX. 

THE  EIGHTH  SPECIES  OF  MALFORMATION. 

SECTION  I.  PAGE 

Description. — The  rectum  in  this  species  is  entirely  absent,  and 
the  colon  generally  ends  in  a  cul-de-sac — There  is  no  sign  of  a 
normal  anus  present,  yet  an  abnormal  one  does  occasionally  exist 
— The  pelvis  in  these  instances  is  sometimes  abnormally  small  and 
contracted— Some  authors  arrange  under  the  head  absence  of  the 
rectum ,  cases  in  which  there  is  only  a  partial  absence  of  the  rectum 
— The  importance  of  this  distinction — Hovr  to  establish  the  diag- 
nosis— The  manner  of  conducting  the  exploration,     -         -         283 — 284 

section  ii. 
The  Treatment,        --------        284—285 

section  iii. 
Cases  anu  Remarks,  -------        285—289 

CHAPTER  X. 

THE  NINTH  SPECIES   OF   MALFORMATION. 

SECTION    I. 

Description. — In  this  species  the  rectum  and  the  colon  are  both 
wanting,  and  some  other  portion  of  the  intestinal  canal  termi- 
nates externally  in  an  abnormal  anus — No  normal  anus  ever 
exists — Fortunately  this  species  of  malformation  is  but  seldom 
met  with — Sometimes  there  is  no  abnormal  anus — The  explora- 
tion and  the  diagnosis,  ---.-_         290 291 

SECTION  II. 

The  Treatment. — Many  of  the  cases  of  this  species  admit  of  pal- 
liative treatment  only,      ----__.         291 292 

section  iii. 

Cases  and  Remarks,  --_-_-_  292 294 

section  iv. 

Recapitulation — A  table  comprising  287  cases,        -        -  -        294 


XVI  TABLE    OF    CONTENTS. 

CIIAPTERXI. 
ABDOMINAL  ARTIFICIAL  ANUS. 

SECTION  I. 

PAGE. 

Genekal  Remarks — The  term  artificial  amis  indiscrimately  applied 
to  the  'preternatural  anus — This  term  is  strictly  applicable  only  to 
such  an  anus  as  is  designedly  established  by  the  surgeon — Preter- 
natural abdominal  anus,  a  merefascal  fistula  of  the  small  intestines 
— Two  operations  proposed  and  advised  for  the  formation  of  an 
ai'titicial  anus  in  the  abdomen — The  establishment  of  su-ch  an 
anus  should  never  be  attempted,  only  as  the  last  alternative — 
Amussat  and  Tiigel  on  the  contrary,  however,  recommend  it  first 
and  last — Some  able  surgeons  proscribe  the  operation  altogctlicr — 
Their  objections  considered — Important  considerations  in  relation 
to  the  operation,  -  _  _  _  295 303 

SECTION  II. 

The  History  of  the  Operation. — Littre',  the  first  individual  in 
modern  times  who  suggested  the  idea  of  forming  an  anus  in  the 
abdomen — Pillore,  the  first  surgeon  who  executed  the  operation 
of  Littre,  in  a  modified  form — Callisen  in  1770  publishes  another 
operation  for  forming  an  anus  in  the  abdomen — The  estimation  in 
which  Callisen's  operation  was  held — Amussat  in  1839  revives, 
improves  and  executes  the  operation  of  Callisen,  -  304—309 

section  iii. 
The  Proceeding  of  Littre,         .  _  _  _  309 311 

section  iv. 
Cases  and  Remarks,  -  -  -  _  .  gu 301 

SECTION  V. 

Compendium. — A  table  comprising  25  cases,  in  which  the  operation 

of  Littre'  was  performed  on  new-born  children,  -         -         321 — 322 

section  vi. 
The  Proceeding  of  Littre,  as  Modified  by  Pillore,        -        323 — 324 

SECTION  vii. 

The  Proceeding  of  Callisen,     -  -  _  _  324 — 325 

section  viii. 
Oases  and  Remarks,  -----  326 — 328 

section  ix. 
The  Proceeding  of  Callisen,  as  Modified  by  Amussat,  328 — 334 

section  x. 

Cases  AND  remarks,            -            _            .  _            .            334 — 345 

section  xi. 

Appreciation,        -            -            _            -  _            345 — 345 

section  xii. 

The  Proceeding  of  Martin,       -            -  _            _            347 — 343 


CORRIGENDA. 

PAGE 

•29.   The  ninth  line  from  the  top,  for  Ohirurgie  read  d«  Chirurgie. 

49.   The  top  line,  for  (i/xiommiMaf  read  (XftdominaJ. 
129.  The  fourteenth  line  from  (he  bottom,  for  <>e  Recini  read  01.  Ricini. 
168.  The  twenty  first  line  from  the  bottom,  for  Iriaugular  read  triangular. 
175.   The  ninth  line  from  the  top,  for  mdeoraie  read  mnderate. 
191.   The  eighteenth  line  from  the  top,  for  Jnuraal  read  Journal. 
202.   The  top  line,  for  cases  which  read  cases  in  which. 
335.    The  eighth  line  from  the  bottom,  for  dilate  read  dilute. 

Explanation  of  plate  third.  The  second  line  from  the  top,  for  Case  X/7/read  Case  XJ^VII. 


EXPLANATION  OF  THE  PLATES. 


PLATE  II. 
Some  of  the  Instruments  employed  in  Proctoplasty,  Colotomy,  &c. 


Figure  1, 

Figure  2. 

Figure  3. 

Figure  4. 

Figure  5. 

Figure  G. 

Figure  7. 

Figure  8. 

Figure  9. 

Figure  10. 
Figure  11. 

Figure  12. 


EXPLANATION. 

Small  Bi-valve  Speculum  Ani. 

Operating  Scalpel  of  medium  size. 

Small  size  Scalpel  for  delicate  work. 

Probe-pointed  curved  Bistoury. 

Cooper's  Hernial  Bistoury. 

Gurved  Sharp-pointed  Bistoury. 

Straight  Sharp-pointed  Bistoury. 

Flexible-Silver  grooved  Director. 

Bull-dog  Forceps  of  Listen,  for  pulling  down  the  end  of  the 

rectum. 
Tumor  Forceps,  for  drawing  down  the  blind  end  of  the  rectmn. 
Round-bellied  Scalpel,  for  making  the  first  incision  of  the 

perinasum. 
Silver  Anal  Canula, 


Plar.p  11 


PLATE  III. 

Plate  III.  represents  a  case  of  membranous  occlusion  of  the  Anus,  as  seen 
tij  Von  Amnion.      [Vide  Case  XIII.] 

EXPLANATION. 

Figure  1,  presents  the  external  appearance  of  this  case. 

After  Von  Amman, 
a — The  penis  in  a  constant  state  of  erection. 
h — A.  considerable  pit  or  depression  near  the  natural   situation  of  the 

anus. 
Figure  2,  presents  the  appearance  of  the  intestines.     After  Von  Ammon. 
a^  a,  a. — The  descending  colon  greatly  distended  with  gas  and  meconium, 

just  where  it  terminates  in  the  rectum. 
h. — The  small  intestines  turned  over  on  the  right  side. 
Figure  3,  presents  the  inferior  portion  of  the  rectum. 

After  Von  Ammon. 

a. — The  rectum. 

h. — The  place  at  which  the  anus  was  closed. 

c. — A  sound  in  the  orifice  made  by  the  operation. 

Figure  4,  presents  the  rectum  laid  open  through  its  entire  length. 

After  Von  Ammon. 
a. — The  inner  surface  of  the  rectum. 
h. — The  folds  of  the  rectum,  or  columns  of  Morgagni. 
c. — The  internal  sphincter,  forming  a  wreath-like  mass,  from  which   the 

membrane  grew  which  had  closed  the  anus. 
cj^  (J, — The  cut  surfaces  of  the  rectal  walls  greatly  thickened. 


Plate  111. 


FlQ.    /. 


J:' 


\ "/ 


^     -       /      I 


PLATE  lY. 

EXPLANATION. 

Figure  1,  represents  tlie  external  appearance  of  an  imperforate  anus  and 
rectum,  in  a  new-born  infant.      [Third  Species.] 

a. — The  prominent  and  continuous  raphd. 

Figure  2,  represents  the  parts  immediately  concerned  in  a  case  of  imper- 
foration  of  the  anus  and  rectum,  as  they  were  observed  by  Von  Ammon  in 
a  five  months'  foetus.     [Vide  Case  L.]  After  Von  Ammon. 

ffl.— The  rectum. 

h. — The  cul-de-sac  of  the  rectum. 

c. — The  cord-like  rudiment  of  the  rectum. 

d. — The  sigmoid  flexure  of  the  colon. 

Figure  3,  gives  a  representation  of  the  parts  concerned  in  Dr.  W.  P 
Hill's  case  of  imperforate  anus  and  rectum.     [Vide  Case  LXILJ 

a. — A  portion  of  the  perinfeum. 

t,  h. — The  ureters. 

e. — The  rectum  terminating  upon  the  neck  of  the  bladder, 

d.: — The  urethra. 

«.. — The-  bladder. 


Plate  IV 


ife  ^ 


PLATE  V. 

Plate  V.  gives  a  full  representation  of  the  celebrated  case  of  M.  Amussat, 
and  his  peculiar  operation.     [Vide  Case  XLII.j 

EXPLANATION. 

Figure  1,  is  an  imaginary  representation  of  this  case.  M.  Amussat,  in 
order  to  render  the  details  of  his  operation  intelligiVjle,  gave  a  plan  of  the 
parts  a-s  he  supposed  them  to  exist  before  the  operation.  He  took  pains  to 
make  the  analogy  as  complete  as  possible,  by  taking  his  sketch  from  a  left- 
side view  of  the  interior  of  the  pelvis,  in  a  female  child  who  died  a  few 
days  after  birth.  All  the  organs  of  the  pelvis  had  been  cut  in  two,  part  of 
the  rectum  was  removed,  to  represent  the  deficient  portion  of  the  intestine, 
and  the  anus  was  made  to  communicate  with  the  vagina.      After  Boitrgery. 

a,  h. — The  anus  and  vulva,  which  were  properly  formed,  and  communi- 
cated with  the  vagina  onl3^ 

c. —  The  extremity  of  the  rectum  forming  a  cul-de-sac  below  tne  sacro- 
vertebral  angle,  and  having  no  communication  with  either  the  anus 
or  vagina. 

fZ.— The  bladder. 

e. — The  superior  portion  of  the  rectum. 

Figure  2,  represents  Amussat's  operation  in  this  case. 

After  Bourgery. 
«,  h. — The  fingers  of  an  assistant. 

c. — The  sound  introduced  into  the  vagina. 

d. — The  loop  of  a  ligature. 

f. — The  bistoury. 

Figure  3,  represents  the  conclusion  of  this  operation.  The  horizontal 
wound  is  closed  by  sutures,  and  the  margins  of  the  longitudinal  wound  are 
united  to  the  divided  portions  of  mucous  membrane.         After  Bourgery, 


k-'^ 


I 


/r'> 


PLATE  VI. 


EXPLANATION. 


Figure  1,  represents  a  case -of  complete  imperforation  of  the  rectnm, 
situated  some  distance  above  a  normal  anus.     fFourtli  Species.] 

After  Baillie. 

a. — The  rectum. 

h. — The  cul-de-sac  and  termination  of  the  rectum. 

c. — The  normal  anus. 

d. — A  bougie  introduced  into  the  short  anal  canal,  as  far  up  as  to  the 
blind  end  of  the  rectum. 

e. — The  anterior  surface  of  the  bladder. 

/. — The  posterior  surface  of  the  bladder. 

g. — A  part  of  one  of  the  ureters. 

Figure  2,  represents  the  part  concerned  in  a  case  oNmperforation  of  the 
rectum  above  a  normal  anus,  as  observed  by  Mr.  Ford.     [Vide  Case  LXX.] 

a. — The  rectum  laid  open  through  its  entire  length. 

b. — The  ligamentous  substance  described  by  Mr.  Ford. 

c. — The  normal  anus. 

d. — The  place  at  which  the  rectum  was  occluded. 


Plate  VI 


Fij.  /. 


/ 


w<. 


.i>«t»v 


6'        d 


PLATE   VII. 

Plate  YII.  gives  a  representation  of  the  rectum  and  part  of  the  colon  of 
a  new-born  infant,  seen  by  Yon  Amnion,  in  whom  existed  a  membranous 
closure  of  the  rectum  three-fourtlis  of  an  inch  above  a  normal  anus.  The 
child  was  in  a  dj'ing  state  when  Von  Amnion  was  called,  and  no  operation 
was  performed.     [Fourth  Species.]     {Op.  Clt.  Tah.  X.  Figs.  9,  10,  11.) 

EXPLANATION. 

Figure  1,  presents  a  front  view  of  the  rectum,  from  the  point  of  occlu- 
sion to  its  connection  with  the  colon.  After  Von  Ammon. 
a. — The  rectum  greatlj'  distended. 
/;. — The  cul-de-sac  of  the  rectum  and  point  of  occlusion. 
c. — The  sigmoid  flexure  of  the  colon. 
(J.— The  bladder. 

Figure  2,  gives  a  lateral  view  of  the  rectum  in  the  same  case. 

After  Von  Ammon. 
a. — The  large  sack-like  rectum. 

b. — The  point  of  occlusion  of  the  rectum. 

r. — The  circular  fibres  of  the  external  sphincter. 

L — The  normal  anus. 

e. — The  bladder,  small  and  contracted. 

/. — The  urethra. 

g. — The  sigmoid  flexure  of  the  colon. 

Figure  3,  represents  the  inferior  portion  of  the  rectum  laid  open  from 
the  verge  of  the  anus  to  the  occluding  membrane.  After  Von  Ammon 

a. — The  blind  sac  of  the  rectum. 
h. — The  membranous  closure  of  the  rectum. 
<r,  c. — The  cut  surfaces  of  the  parietes  of  the  rectum. 


PLATE  VIII. 

Plate  VIII.  gives  a  full  representation  of  the  interesting  case  reported 
by  M.  Cruveilhier  of  a  new-born  infant  in  whom  there  existed  an  imper- 
foration  of  the  anus  and  a  prolongation  of  the  rectum.       [Vide' Case  CV. ) 

EXPLANATION. 

Figure  1,  represents  the  perinaeum  and  the  genitals  of  this  case. 

After  Cruveilhier. 

a  — The  artificial  opening  made  at  the  normal  situation  of  the  anus. 

h. — The  rugose  and  prominent  raphe'  which  became  linear  as  soon  as  meco- 
nium was  voided. 

c. — The  abnormal  aperture,  or  anus. 

Figure  2,  gives  a  clear  idea  of  the  origin,  the  direction  and  the  termina- 
tion of  the  accidental  canal.  After  Cruveilhier. 

a. — The  rectum. 

/'. — The  cul-de-sac  of  the  rectum. 

f,  c,  c. — The  accidental  canal  from  its  origin  the  rectum,  to  its  termina- 
tion at  the  glans  penis. 

d. — The  glans  penis. 

Figure  3,  presents  still  a  further  view  of  the  relation  of  the  parts  of  the 
same  case.  After  Cruveilhier. 

a. — The  bladder. 

h,  h. —  The  rectum. 

c. — The  cul-de-sac  of  the  rectum. 

rf.— The  origin  of  the  accidental  canal. 


Plate  Vlli 


X. 


FUf.J. 


Wl 


Ct-.-i 


FCcj.Z. 


F,^.3. 


PLATE  IX. 

EXPLANATION. 

Figure  1,  gives  a  horizontal  section  of  the  pelvis,  representing  an  imagi- 
nary case  by  Von  Amnion,  in  which  the  anus  is  imperforate,  and  the  rectum 
comnmnicates  with  the  vagina.  After  Von  Ammon. 

«,  a. — The  rectum  and  sigmoid  flexure  of  the  coloin. 

&.— The  bladder. 

c. — The  vagina. 

d. — The  recto-vaginal  opening. 

e. — A  small  elastic  urethral  bougie  introduced  by  the  vagina  through  the 
recto-vaginal  opening  into  the  rectum, 

/,/. — The  uterus  with  the  ovaria. 

g The  symphysis  pubis. 

li.     The  soft  parts  of  the  anal  region.  • 

i. — The  blind  end  of  the  rectum. 

A". — The  superior  extremity  of  the  left  leg. 

Figure  2,  represents  the  parts  immediately  concerned  in  the  case  of  an  in- 
fant, as  seen  by  Wreisberg,  in  whom  the  anus  was  imperforate,  and  the  rec- 
tum terminated  in  the  bladder.  [Vide  Case  CXXXIV.]      After  Vun  Ammon. 

a. — The  rectum. 

h. — The  bladder  laid  open. 

c. — The  urethra. 

d. — The  penis. 

e,  e. — The  umbilical  arteries. 

/. — The  umbilical  vein. 

g. — The  ligament  leading  from  the  bladder  to  the  umbilicus. 

h. — The  urachus  within  the  ligament. 

i. — The  recto-vesical  opening. 

Figure  3,  represents  the  remarkable  case  of  Casimir  de  Chonski  in  which 
the  rectum  was  absent,  and  the  colon  terminated  in  the  bladder  by  a  pro- 
longation. In  this  case  existed  bilobation  of  the  bladder,  of  which  \t  i>i  sl 
beautiful  specimen,  umbilical  hernia,  and  a  "preternatural  anus.  [Vide 
Case  CXXXV.]  After  Von  Ammon. 

a. — The  ileum  severed. 

^.— The  annulus  umbilicalis. 

c. — The  funiculus  umbilcalis. 

d. — Hernia  umbilicalis. 

e. — Vena  umbilicalis. 

/• — The  colon  descending  with  a  considerable  curve  and  prolongation,  to 
communicate  with  the  bladder. 

9,  g. — The  bilobed  bladder. 

/t.— The  termination  of  the  prolonged  colon  in  the  bladder,  between  the 
ureters. 

i,  i. — The  ureters. 

j- — A  probe  in  the  preternatural  anus. 

k. — The  urethra  severed. 

/,  m. — The  two  vasa  deferentia. 


Plate  IX 


PLATE  X. 

EXPLANATION. 

Figure  1,  represents  the  very  interesting  case  reported  by  Mr.  Lucas, 
in  which  the  rectum  terminated  in  a  cul-de-sac  two  inches  above  its  natu- 
ral outlet,  and  communicated  with  the  bladder.       [Vide  Case  CXXXVI] 

After  Mieban. 

a. — The  rectum,  terminating  nearly  two  inches  from  the  anal  aperture. 

I). — The  bladder. 

c. — A  probe  passed  through  a  small  opening  by  which  the  pouch-like 
termination  of  the  rectum  communicated  with  the  bladder. 

d. — A  probe  passed  from  the  anal  aperture  upwards,  showing  its  deter- 
mination in  the  bladder  ;  the  vesical  oritice  being  guarded  by  a  val- 
vular fold  of  mucous  membrane. 

f,  e,  c. — A  probe  passed  from  the  external  orifice  of  the  urethra  aloug 
that  tube  into  the  bladder. 

/. — The  distended  portion  of  tho  urethra,  the  diameter  of  which  is  equal 
to  a  No.  li  bougie. 

g. — The  distended  scrotum  communicating  with  the  urethra  for  fully 
half  its  length,  and  lined  with  a  coating  of  lymph,  which  presented 
extravasation  of  the  urine,  and  the  liquid  fasces  into  the  cellular  tissue. 

/;. — A  small  cul-de-sac  corresponding  to  the  urachus. 

Figure  2,  represents  the  case  reported  by  the  late  Dr.  Steele,  of  Saratoga 
Springs,  in  which  the  rectum  terminated  in  the  neck  of  the  bladder. 
[Vide  Case  CXXXIX.] 

a. — The  rectum  and  r)art  of  the  colon. 

6.— The  bladder. 

r. — The  penis. 

Figure  3,  represents  an  imaginary  section  of  the  pelvis,  to  explain  the 
imperforation  of  the  anus,  and  the  urethra  as  they  were  supposed  to  exist 
in  M.  Roux  de  Brignole's  case. 

ffl,  a. — The  interior  of  the  bladder. 

h,  h. — Section  of  the  prostate. 

c. — The  vesicula  seminales. 

d. — The  vas  deferens. 

f,  e. — The  interior  of  the  rectum.. 

/; — Supposed  termination  of  the  rectum  in  front  of  the  neck  of  the  bladder. 

g. — The  penis. 

h. — The  opening  of  the  meatus. 

i. — The  bulb  of  the  urethra. 

k. — The  root  of  the  right  corpus  cavernosum. 

I. — Section  of  the  pubis. 

ni. — Space  between  the  pubis  and  the  bladder. 

n, — The  urachus. 

0. — The  muscles  of  the  abdomen. 

p. — The  skin. 

q,  r. — The  peritonaeum  lining  the  cavity  of  the  abdomen. 

>v,  s. — The  sacrum. 

/,  t.  —The  incision  in  the  perinseum. 

n. — The  bistoury,  its  point  in  the  rectum. 


P]Qr o  Y 


PLATE  XI. 

Plate  XI.  gives  the  representation  of  a  remarkable  foetus  observed  by 
M.  Cruveilhier,  in  which  the  anus  was  imperforate,  and  the  rectum  termi- 
nated in  the  bladder.     [Vide  Case  CXL.] 

EXPLANATION. 

Figure  1,  represents  the  ano-perinseal  region  of  this  case.  It  will  be 
observed  that  the  perinseimi  is  enormous  in  its  antero-posterior  diameter. 

After  Cruveilhier. 

Figure  2,  represents  a  section  of  the  pelvic  cavity  containing  the  soft 
parts.  After  Cruveilhier. 

a. — The  bladder. 

h. — The  rectum  which  opens  into  the  bladder,  and  with  the  base  of 
which  is  perfectly  confounded. 

c,  c. — The  ureters. 

d. — The  prostatic  portion  of  the  urethra. 

Figure  3,  represents  the  rectum  of  this  same  case,  opening  into  the 
posterior  part  of  the  bas-fond  of  the  bladder  by  a  large  infundibuliform 
aperture.  After  Cruveilhier. 

a. — The  rectum  opening  behind  the  bladder. 

h. — The  prostatic  portion  of  the  urethra. 

c. — The  infundibuliform  aperture  of  the  rectum  communicating  with 
the  bladder. 

d. — The  bladder  laid  open,  showing  its  interior. 


PlnhnX 


Fifj.  1. 


^^I^r 


'  itiy 


iS^g!*'"' 


Fii^  3.        jl 


PLATE  XII. 

Plate  XII.  gives  the  representation  of  the  case  of  a  male  child,  present- 
ing an  imperforation  of  the  anus  with  the  rectum  terminating  in  the  blad- 
der.   It  was  seen  by  Von  Amnion,  and  operated  on  without  success. 

s 
EXPLANATION. 

Figure  1,  gives  the  external  appearance  of  this  case. 

After  Von  Ammon. 
a,  a. — The  thighs  slightly  elevated. 

h. — A  depression  or  pit  in  the  exact  situation  of  the  absent  anus. 
c. — The  scrotum. 

d. — Another  depression  corresponding  with  the  termination  of  the  rec- 
tum within. 

Figure  2,  represents  a  side  view  of  the  internal  parts  directly  concernec 
iu  this  case.  After  Von  Ammon 

«.— The  bladder. 
h. — The  inferior  extremity  of  the  colon. 

c.  —The  rectum  adhering  to  and  terminating  in  the  posterior  part  of  tht 

bladder  between  the  insertion  of  the  ureters. 

d,  d. — The  ureters. 

e,f. — The  remaining  portion  of  the  integument  and  cellular  tissue  of  tht 
perinajum  not  cut  away. 

g. — The  place  where  the  depression  was,  and  into  which  the  bistour;y 
was  plunged. 

Figure  3,  presents  another  view  of  the  relation  existing  between  tin 
several  internal  parts  of  this  case.  After  Von  Avimov. 

ffl.  —  The  bladder,  presenting  its  posterior  aspect. 

h,  h. — The  ureters,  the  right  one  presenting  a  remarkable  turn  in  it. 

c,  c. — The  kidneys. 

d. — The  portion  of  the  perinseum  not  removed,  in  which  the  depression 
was  at  the  normal  situation  of  the  anus. 

e. — The  rectum  laid  open  and  its  cavity  exposed,  so  that  the  ojifice  com- 
municating with  the  bladder  is  distinctly  seen. 

/. — The  recto-vesical  orifice  between  the  ureters. 


V 


n  \' 


FL(f.    I. 


I 


PLATE  XIII. 

EXPLANATION. 

Figure  1,  represents  the  case  reported  by  Fleischmann,  in  which  the 
anus  and  the  rectum  were  entirely  wanting,  and  the  colon  terminated  in  a 
blind  sac.  The  abdomen  is  opened  and  its  parietes  turned  over,  tha^ 
aflfording  a  correct  view  of  the  situation  of  the  intestines,  especially  show- 
ing the  character  of  the  descending  colon.     [Vide  Case  CCLIV.] 

After  Von  Amman. 
a. — The  liver  above  the  commencement  of  the  ascending  colon. 
b. — The  ascending  colon  which  here  takes  place  of  the  caecum,  and  is 
divided  into  two  branches,  from  one  of  which  springs  the  appendi- 
cula  vermiformis. 
c. — The  descending  colon,  hanging  loosely  in  the  abdominal  cavity. 
d. — The  blind  end  of  the  colon, 
e,  e,  e,  e. — The  parietes  of  the  abdomen. 

Figure  2,  represents  the  anatomical  condition  of  the  colon  in  a  case  of 

imperforation  of  the  anus  and  rectum,  as  observed  by  Von  Ammon.     The 

descending  colon  presents  several  sac-like  dilations  before  passing  down 

behind  the  bladder  to  terminate  in  a  cul-de-sac  in  the  rectum. 

After  Von  Ammon. 
a. — The  descending  colon. 

6,  &. — The  sac-like  dilations  of  the  colon. 

c. — The  bladder,  behind  which  the  colon  passes. 

d,  e.— The  small  intestines  in  a  normal  condition. 


PlateX 


Fi-vi .  I 


Fiq.  2. 


PLATE   XIV. 

Plate  XTV.  gives  a  representation  of  the  case  of  a  male  child  presenting 
an  imperforation  of  the  anus  and  rectum,  unsuccessful!}-  operated  on  by  Von 
Amnion.  The  autopsy  in  this  interesting  case  clearly  revealed  the  cause 
of  the  failure  of  the  operation.  l"he  rectum  for  about  two-thirds  of  its 
entire  length  was  greatly  dilated,  presenting  the  form  of  a  pouch ;  but 
gradually  tapered  off,  and  terminated  blindly  in  a  small  point  within  a 
few  lines  of  the  posterior  wall  of  the  scrotum. 

Notwithstanding  the  incision  was  made  in  the  proper  place,  and  deep 
enough,  yet  it  entirely  failed  to  reach  the  rectum,  because  this  organ  was 
further  removed  from  the  sacrum  towards  the  front  than  the  natural,  and 
thus  occupying  an  abnormal  position.  [Vide  page  102.]  Had  this  fact 
been  previously  known  to  Von  Amnion,  and  his  incision  directed  much 
more  towards  the  inter-pubic  space  than  towards  the  sacrum,  the  rectum 
would  doubtless  have  been  easily  opened.     (Opus  Citatum,  S.  48.) 

EXPLANATION. 

Figure  1,  represents  a  front  view  of  the  pelvic  region  of  this  case.  The 
scrotum  and  penis  are  much  corrugated,  and  drawn  closely  to  the  abdo- 
men, the  latter  presenting  a  para-phimosis  congenita.  The  right  half  of 
the  scrotum  is  turgid,  and  contains  the  ttisticle,  w^hilst  the  left  half  presents 
less  turgesence,  the  testicle  not  having  descended  into  it. 

After  Von  Ammon. 
«,  a. — The  interior  parietes  of  the  abdomen. 
b. — The  symphysis  of  the  pubis. 
c.  -  The  scrotum. 
d. — The  penis. 

f. — The  right  half  of  the  scrotum. 
/',  q. — The  dilated  rectum. 

//,  /. — The  colon  with  its  sigmoid  flexure  much  smaller  in  diameter  than 
natural. 

Figure  2,  represents  a  side  view  of  a  portion  of  the  contents  of  the 
j)e]vis. 

After  Von  Ammon. 
a. — The  rectum. 

'^- — 'f  he  rectum  terminating  blindly  in  a  conical  point  beneath  the  penis. 
'■•. — The  bladder  opened  from  the  side. 
d. — The  urethra  opened  from  the  side, 
f- — The  artificial  orifice  made  at  the  normal  situation  of  the  anus. 

Figure  3,  presents  a  po.-terior  view  of  the  contents  of  the  pelvis. 

After  Von  Ammon. 
a,  a. — Both  halves  of  the  scrotum. 
h. — A  probe  indicating  the  entrance  and  the  direction  of  Von  Ammon's 

incision  behind  the  rectum,  and  between  it  and  the  sacrum, 
f,  c. — The  superior  part  of  the  rectum  descending  in  the  form  of  a  cone 

in  front  of  the  incision. 
(■?,  d. — The  intestines, 
f,  e. — The  interior  surface  of  the  peritongeum. 


PlateXlV. 


Fuf.  1. 


PLATE  XV. 

Plate  XV.  gives  representations  of  the  operation  for  the  formation  of 
abdominal  artificial  anus. 

EXPLANATION. 

Figure  1,  presents  a  front  view  of  the  surgical  relations  of  the  colon. 

After  Bernard  and  Huette. 
a^  a. — The  integuments. 
h,  h. — The  external  oblique  muscle. 
c. — The  internal  oblique  muscle. 
d. — The  transversalis  muscle. 
e. — The  lower  edge  of  the  liver. 
/. — The  distended  caecum. 

g. — The  descending  colon  with  the  sigmoid  flexure  seen  below. 
h. — The  transverse  colon. 

Figure  2,  presents  a  posterior  view  of  the  parts  concerned,  as  shown  by- 
removing  the  dorsal  structures.  After  Bernard  aud  Huette. 

a. — The  peritonaeum. 

It. — The  kidney. 

c. — The  mesentery. 

d. — The  bowels. 

e. — The  colon. 

/. — The  spine. 

Figure  3,  represents  the  operation  of  Littrd  for  the  formation  of  an 
artificial  anus  at  the  right  groin.  After  Bernard  and  Huette. 

a,  a. — The  outline  of  the  colon. 

h,  b. — The  extent  of  inguinal  incision  in  the  integuments. 

c,  c. — An  instrument  passed  beneath  the  distended  colon,  in  order  to 
bring  it  to  the  front  wound. 

d. — The  point  of  the  colon  which  is  to  be  perforated. 

Figure  4,  represents  the  shape  and  appearance  of  the  anus  formed  by 
the  operation  of  Littre'.  The  long  diameter  of  the  opening  corresponds  to 
the  line  of  the  groin,  and  the  bowel  is  so  attached  to  the  edges  of  the  in- 
cision in  the  abdomen  as  to  prevent  contraction  of  the  orifice,  or  the  escape 
of  the  bowel  into  the  abdomen.  After  Bernard  and  Huette. 

Figure  5,  represents  the  operation  of  Littre',  as  modified  by  Pillore. 
Section  of  the  ca;cuni.  After  Bourgery. 

Figure  0,  represents  Pillore's  operation  for  iliac  artificial  anus  completed. 
The  wound  in  the  intestine  united  to  the  wound  in  the  integument  by  six 
I  <;ints  of  twisted  suture.  After  Bourgrry. 


PlahnXV 


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Fiq.  Z 


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Fiuf  3 


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d:   :% 


PLATE  XVI. 

Plate  XVI.  illustrates  Callisen's  operation  for  abdominal  artificial  anus, 
as  modified  by  Amussat. 

EXPLANATION. 

Figure  1,  represents  the  operation  of  Amussat,  for  tlie  formation  of  aa 
abdominal  anus  in  the  left  lumbar  region. 

After  Bernard  and  Huetle. 
a.  a. — The  outlines  of  the  descending  colon. 
6,  6. — The  extent  of  the  incision  in  the  integuments. 

c,  c. — An  instrument  placed  beneath  the  bowel  to  render  it  prominent. 

d,  d. — Ligatures   passed   through  the  bowel  in  order  to  attach  it  to  the 

sides  of  the  wound,  before  it  is  perforated. 
Figure  2,  represents  the  appearance  of  the  artificial  anus  formed  in 
Amussat's  operation,  showing  the  position  of  the  sutures  and  the  character 
of  the  opening.  After  Bernard  and  Huette. 

Figure  3,  represents  the  lumbar  artificial  anus  established  bj'  Amussat. 

After  Bonrgery. 


PlaLeXVl 


F"J    ' 


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Fvg    3 


Ftg.  Z 


ON   THE 

CONGENITAL  MALFORMATIONS 

OF     THE 

RECTUM  AND  ANUS. 


CH^I^TER   I. 

INTKODUCTION. 

SECTION    L 

BIBLIOGRAPHY. 

A. 

Adair   (William.)    Medical  Facts  and   Observations.      Vol. 

IV. p.  27.  London:  1793. 
Adrian!  (Petrus.)  Ruyscli.  Adversaria  Anatomica.  decad.  II. 

(J.  10.  p.  43. 
Ainswortli   (S.   F.)   Boston  Medical   and  Surgical  Journal. 

Vol.   LVII.  p.   239.   Boston:  1857. 
Albucasis.   De  CTiirurgia.   Lih.  II.   cap.  79.  Argent  :    1532. 

Folia. 
Alix  (Mat   Franc.)   Ohservata  Chirurgica.  tome  III.  p.  203. 

Altenhurg  :    1774. 
Allen    (Robert.)    System    of    Pathological   and    Operative 

Surgery.    Vol.  III.   Part  II  p.  491.    Edinluujh:    1824. 
Amatus   (Lusitanus.)    Guratiomim  Medicinalium.    Cent.  II. 

curat.    10.     Venet :   1653. 
Ammon  (Friedricli  August  Von.)   Pie  Angeborenen   Chirur- 

giscJien   Kranldieiten   des  Menschen  in  Ahhildungen  dar- 

gesteUt  und  durch  erlduternden    Text   erhldrt  S.   40.  43. 

Tal.   X.   XI    Berlin:   1842. 

17  2 


18  IXTIiODUCTTON. 

Amussat  (J.  Z.)  Histoire  cfune  Ojperation  d^Anus  artifi- 
ciel  jpn^atique  avec  sucees  jpar  un  nouveau  Procede,  da/ns 
un  cas  d  ''Absence  congeniale  de  I  Anus  ;  suivie  de  quel- 
ques  reflexions  silt  les  Obturations  du  Mectum.  Lu  d  I ' 
Academie  des  Sciences,  le  2  Novembre.  1835.  {Gazette 
Medicale  de  Paris.  28  Novembre.  1835.) 

Memoir e  sur  la  Possihilite  d '  etablir  tin  Anus  artificiel 
dans  la  Pegion  loinbaire  sanspenetrer  dans  le  Peritoine. 
Lu  a  I  Academie  Royale  de  Medicine,  le  I  er  Octobre,  1839. 
Peuxieme  Memoire  sur  la  Possibilite  dHablir  un  Anus 
artificiel  dans  les  Regions  lomhaires  sans  wvrir  le  Peri- 
toine. Lu  a  I  Academie  Poyale  de  Medicine.  6  Septembre, 
1841. 

Troisieme  Memoire  sur  la  Possibilite  d^ etablir  une  ouver- 
ture  artificielle  sur  le  Colon  lombaire  gauche  sans  ouvrir  le 
Peritoine,  chez  les  Enfans  imperfores.  Lu  d  I  Academie 
Poyale  des  Sciences,  le  4  Juillet,  1842.  {JO Examinateur 
Medical   de  Paris.   Annee  1843.   Nos.  16,  17,  18.) 

Andral  (G.)  Precis  d  Anatomic  Pathologigue.  tome  L.  p. 
109.  Paris :  1829.  Also,  Dictionnaire  de  Medicine,  tome 
X/F.i?.  438. 

Andrews  (S.  L.)  Peninsular  Journal  of  Medicine  and  the 
Collateral  Sciences.   1839. 

Arand  (     )  Observat.  Med.  Chirurg.  observ.  LY.  ])-  28. 

Aristotle.  De  Generatione  Animalium.  Lib.  LV.  C.  4. 
in  fin. 

Arnott  (James.)  Lectures  on  the  Diseases  of  Lnfancy  and 
Childhood.  By  Charles  West.  Lecture  XXXL.  p.  376.  2c? 
Amer.   Edit.   Philccdelphia :    1854. 

Asliton  (T.  J.)  A  Treatise  on  the  Diseases,  Jnjxiries  and  Mcd- 
f(yrmations  of  the  Rectum  and  Anus.  Chapter  XIX.  p. 
326.  London:  1854. 

Aver  (    )  Boston  Medical  and  Surgical  Journal.    Vol.  L  VI L 
p.  510.  Boston :  1858. 


INTUODUCTION.  19 

B. 

Baillie   (Mjittlicw.)   Morh'id  Anatomy,      j^-    ^^^-     London : 

1833.   Ed.  hy  Wardrop.  Also,  Series  of  Engravings,  p.  77. 

Fasciculus.  IV.   Plate  V.  Figure  4.  London  :  1833. 
Barbette   (PjiuI.)      Opera     Chirurgico-Anatomica.     Lih.   I. 

Cap.  XIII.  Lugd.  Batac. :  1672. 
Barbout  (Antoine  Francois)  Suite  du  Cours  d  ^Accouchemens. 

torne  II.  p.  59.  Paris :  1775. 
Baroii  (M.)  Pevue  Medicalede  Paris.  Pecembre,  1835.  p.  418. 
Bartholiniis   (Tliomas.)    Historianum   Anatomicarum    Pari 

orum  Centuria.   cent.   I.    Ohserv.     65.    p.  113.    Ilafnice : 

1654. 
Barton   (John  Rhea.)   Medical  Recorder.  Vol.  VII.  p>.  357. 

Philadelphia :  1824. 
Baudens  (    )  Gazette  des  Ilopitaux  de  Paris.   AmiSe  :  1842. 

Wo.  XXV n. 

Baudelocque  (A.  C.)   Academic  des  Sciences  de  Paris.  Aoiit 

— Octohre,  1844.   Also,  London  Lancet.    Vol.  I.  February, 

1845. 
Baux  (    )  Journal  de  Medicine,  tome  VIII.  p.  59. 
Beauregard  (    )  Bacher   Journal  de  Medicine,  tome  I.  p.  ^^ 

Janvier,  1786. 
Bedford    (Gunning   S.)    Clinical    Lectures  on    Diseases    of 

Women  and   Children,    p.  295.  325.    Fifth    Edit.   New- 

Yorh:  1857. 
Bell   (Benjamin.)      A   System    of  Surgery.     Vol.  II.  Chapt. 

XIX,  p.  275.  Third  Edit.   Edinhurgh  :  1787. 
Benivenius  (Anthony,)  of  Florence.    Lihellus  de  Ahditis  nun- 

nullus  ac  mjvrandis  Morborum  et  Sanationum  Causis.  cap. 

86.  Florence  :  1503.  in  4  to. 
Bertin   (M.)   Memoire  de  I  "^Academic  Poyale  des  Sciences  de 

Paris.  — Annee  :  1771. 
Bigelow   (Henry  J.)   Boston  Medical  and  Surgical  Journal. 

Vol.   LVII.p.   240.    Boston:  1857. 


20  INTKODUCTION. 

Billard  (C.  M.)  Traite  des  Maladies  des  Enfans  iioumaux — 

nes  et  a  la  Mamelle.  p.  444.  Paris :  1828. 
Billaimt  (     )  These  Inaugurale  de  Miriel  fits.  Pari^  :  1835. 
Bils  (Ludovicus  de.)  Specimina  Anatomica  et  Yaria  Opuscida. 

p.  10.  Roterod:    1661.  4  to. 
Binninger  (John  Nicol.)  Ohservationuin  et   Curatiomim  Med- 

icmaUum    Centurice.      centur.   II,   ohservat.    81.  p.    222. 

Monibelg :  1673.  Also,  Dlctionnaire  des  Sciences  Medicales. 

tome  XXIV.  p.  129. 
Bird  (P.  Hinckes.)  A  Practical  Treatise  on  the  Diseases  of 

Children.     By  M.  Bouchut.   English  Version.   Book  X. 

Chap.  I. p.  515.  London:  1855. 
Bizet   (    )  These  Inaugurale  de  Miriel  Jils.  Paris :  1835. 
Blandin  (P.   F.)   Dictionnaire   de  Medicine  et  de   Chirugie 

Pratiques.   Paris:  1832. 
Blasius  (Gerardus.)  Ohservationes  Medico — Anatomicce  rari- 

ores.  accedit  Historia  Infantis  monstrosi  a  Domino  Hof- 

inanno.  Ludg.  Botav  :  1711. 
Blasius  (E.)  HanJwortenhuch  gesammten  Chirurgie  imd  Au- 

genheilkunde.  Berlin :  1836. 
Boirie   (    )   Histoire  de  I  ^Acadeniie  des  Science  de  Paris. 

I).  50. 
Bonetus  (Tlieopliilus.)  Sepulchretum,   sive  Anafomia  practica 

ex  Cadaveribus  morho  denatis,  jproponens  Histcrrias   ct  Oh- 
servationes omnium pene  humani  corporis  affectuum,  ipsor- 

timgue  causas  reconditas  revelans.   Genevce  :  1679.    Folia. 
Bonn  (Andreas.)  Papendorf.  Dissertatio  sistens  Ohservationes 

de   ano  infantum  imperforato.     p.    253.   Ludg.   Batav : 

1781.   4:  to. 
Bonnet   (Aug.)      Archieves     Generates     de   Medicine,    tome 

XX.  p.  576.  Paris  :  1829. 
Borelli   (Petrus.)     Historiai^um   et    Ohservationum    Medico- 

Physicarum  Centurice.  Centur.  I.  Ohserv.  77.  Castri:  1653. 
Bouchut  (M.)  A  Practical  Treatise  on  the  Diseases  of  Chil- 


INTRODUCTION.  21 

dren.    BinVs  English  Version.  Book  X.    Chajpt.  1.  p.  512. 
London  :    1855. 
Bougoii   (     )    Lancette  Francaise.   tome  I.  ji.  78.  Beoembre^ 
1828.     Also^  Gazette  des  Ilopitaux  de  Paris.  Annee  1828. 
p.  78. 
Boyer  (M.  le  Baron  Philippe.)  Traite  des   Maladies    Chirur- 
gicales.   tome  IV.    Chap.  XXXVII.  Art.  1.  p. '^U.    Cin- 
quieme  Edid.   Paris  :  1849. 
Braclict  (J.  L.)    Mott's  Veljyeau.    Vol.   III.  p.  1087.  New- 
York:   1847. 
Bravais  (    )  Acts  de  la  SocitU  de  Sante  de  Lyon.  Annee  1801, 

tome  II  p.  97. 
British  and  Foreign  Medical  Review.  Xo.  XXX  VI.  October, 

1844.  Article  XV.  p.  452.     London  :    1844. 
Buckingham  (C.  E.)  Boston  Medical  and  Surgical  Journal. 

Vol.  LVII.p.  334.    Boston  :  1857. 
Burns  (Mien.)  Edinburgh  Medical   and,  Surgical   Journal. 

Vol.  I  p.  137 
Bushc  (George.)  A  Treatise  on  the  Malformations.,   Injuries., 
and  Diseases  of  the  Rectum  and  Anus.     Chap.  Ill  p.  37. 
New- York:  1837. 

C. 
Cabot   (Samuel.)   Boston  Medical  and    Surgical    Journal. 

Vol.  LVII.p.  238.  Boston:  1857. 
Callisen   (Ilemy.)   Systema    Chirurgice  Jiodiernce,   in  TJsiim, 
publicum  et privatum  adornajtum.    tome  II.   p.  688,     Haf- 
7iim:  1800. 
Campbell   (John  P.)   Medical  Repository.    Vol.    V,  p.  45. 

New-York:  1802. 
Camper  (Pierre.)  Memoires  sur  les  Sujets  proposes  pour  les 
Prix     de     VAcademie     de     Chirurgie.     tome    V.    p.    9. 
Paris:    1775. 
Capuron   (Joseph.)    Gazette  Medicate   de   Paris.     Juin   28. 
1834. 


22  INTEODTTCTION. 

Cams   (Carl  Gustav.)   Lehrhach  der  Cynakologie,  &c.  Band 

II.  S.  mi.  Leipzig :    1820. 
Carvenon  (     )  Sedillot,   Recueil  Periodique.  tome  II  p.  36. 
Caussade  (    )  Gazette  des  Hopitaux  de  Pains.  Mars  29,  1834. 
Cavenne  (     )   Archives   Generales   de  Medicine   de  Paris. 

Mai,  1824.  tome  V.  p.  63. 
Chamberlaine  (William.)   Memoires  of  the  Medical  Society 

of  London.  Vol.  V.   Art.  XXIII  p.  206.  London:  1799. 
Clielius   (Maximilian   Joseph.)    Ilandhuch     der     Chirurgie. 

Band  II  S.  27.  Heidelberg  unt  Leipzig  :    1827. 
Chevers  (JSTorman.)   Lndian  Annals.  No.  L.p.  296.  1854. 
Chonski  (Casimir  de.)  Dissertatio  L.  de  vitio  quodam  primce 
formationis  inferiorern  potissimum  tuhi  intestinalis  partem 
et  vesicam  urinariam  spectante.    C.  tab.  Berol,  1837.  4^0. 
Clark  (A.  Bryant.)  Boston   Medical   and  Surgical  Journal. 

Vol.  XL  VI  p.  100.  Boston  :  1852. 
Clement   (    )    Nouvelle   Bibliotheque    Medicate   de   Paris, 

Annee  1829.   tome  II.  p.  99. 
Collins   (Robert)   A  Practical  Treatise  on  Midwifery,    p. 

509.     London:   1835. 
Colson  (A.)  Journal  Ilebdomadaire   de  Medicine  de  Paris. 

Annee.  1829.  tome  II.  p.  150. 
Condie  (D.  Francis.)  A  Practical  Treatise  on  the  Diseases  of 

Children,  p.  \%\.  Philadelphia  :  1844. 
Cooke  ("William)  English  Translation  of  Morgagni.    Vol.  II 

p.  110.  Boston  :  1824. 
Cooper  (Samnel.)  Dictionary  of  Practical  Surgery.  Reese's 
American  Edition.  Vol.  I.  Art.  Imperforate  Anus.  p.  155. 
New-Yorh:  1848. 
Copeland  (Thomas.)  Observations  on  the   Principal  Diseases 

of  the  Rectum  and  Anus.  p.  174.  london  :  1814. 
Costello  (William  B.)  Cyclopxedia  of  Practical  Surgery.   Vol. 
I.  Art.  Anus. p.  343.  London:  1841.  .» 


INTKODUCTION.  23 

Courtial  (Jean  Joseph.)  Nouvelles  Observations  Anatomiques 

sar  les  Os.p.  147.  Le'ule  :  1704-. 
Cruveilliier  (Jean.)    Anatomie  PatJiologique   du    Corps  IIu- 

'Uiain.  tome  I.  livraison  II.   Planche  VI.  Figs.  6,  7,  8.  et 

livraison  II.  Planche  II.  Pigs.  1,  5,  6.   Bruxelles  :  1833. 

1834.    Also,  Revue  Medieale  de  Paris.  Annce.  1833.  tome 

II.  2?.  422. 

D. 

Danzel  (    )  IIdser''s  Archiv.  Band.  IX.  Heft  3.  8.  284. 
Davies  (Redfern.)  Edinhurgli  Medical  Journal.  No.  XXXIII. 

llarch,  1858.  Art.  lY.p.  807. 
De  Jessieu.  Illstoire  de  V Academic  des  Science.  Annee  1719. 

j9.  42. 
De  La  Faye   (George.)     Principes   de    C/iirurgie.    p.    358. 

Paris :  1811. 
De  La  Marre   (    )    Journal  de  Medicine  de  Paris.  Annee 

1770.  tome  XXXIII.  p.  510. 
De  La  Motte  (    )  Traite  complet  des  Accoucliemens  naturels^ 

non-naturels,    et    contre    ISature.     Liv.    I.     chap.    XX. 

Paris :  1765. 
De  Lesalle  (    )  Bulletin  de  la  Societe  Medieale  d' Emulation 

de  Paris.      Juin^  1824. 
De  Lens  (    )  Revue  Medieale  de  Paris.  3Iai,  1835.  p.  285. 
Delmas    (      )    Bouisson.      TJiese    de    Concours    de    Paris. 

Annee  1851. 
Denonvilliers   (    )    Practical  Treatise  on    the  Diseases  of 

Children.    By  M.  Bouchut.      Bird^s    English     Version 

p.  516.     london  :  1855. 
Desault  (Pierre.)    Journal  de  Chirurgie.    tome  IV.  p.  248 

Paris:  1794. 
Desgenettes  (R.)  Gazette  Salutaire. 
Desgranges  (    )  Voir  le  second  Memoire  sur  Venterotomie  par 

Fine^    dans  le    6  volume    des    Annates  de  la  Societe    de 

Montpellier. 


24  INTRODUCTION. 

Desormeaux  (P.)     Dlctionnaire     de     Medicine    de    Paris, 

tome  XV.]).  403. 
Devilliers    (    )    Revue    Medicale    de    Paris.     Mai,    1835, 

p.   286. 
Dewees  (William  P.)  A  Comjyeiidious  System  of  Midwifery. 

Chaj).  XIV.  ^.  215.  PhiladelpUu  :  1832. 
Dieffenbach  (Job  aim  Friedricb.)  Operative  Chirurgie.   Band. 

I.S.670.  Leipzig:  1845. 
Dionis  (Pierre.)  Cours  d""  Operations  de  CJiirurgie  demonstrees 

au  Jardin  du  Rio.     tome  I.  p.  390.    Huiteme  Edit,  par 

De  La  Faye.    Paris :  1782. 
Dodonseus  (Eembertus.)  Annotationes  ad  Benevium.  cap.  IX. 
Dorsey  (Jobn  Syng.)  Elements  of  Surgery.      Vol.  II.  Chap. 

LXIV.p.4,65.   MEdit.     Philadelphia :  1^"^^. 
Druitt  (Robert.)    The  Principles  and  Practice  of  Modern 

Surgery.     Edited  hy  F.   W.  Sargent,  M.  D.      Chap.  XIX. 

p.  446.     Philadelphia :  1858. 
Dubois  (Anton.)  Recueil  Periodique  de  la  SociSte  de  Medicine 

de  Paris,  tome  III.  p.  125. 
Dubois  (Paul.)    Gazette  des  Hopitaux  de  Paris.   No.  LXX. 

Juin  16,  1835.  p.  280. 
Duges  (Anton.)  Recherches  sur  les  Maladies  les  plus  impor- 

tantes    et    les    tnoins    connues    des  enfans   nov/oeaux-nes. 

Paris:  1821. 
Dumas  (    )   Recueil  Periodique  de  la  SociSte  de  Medicine  de 

Paris,     tome  III.  p.  46. 
Dupuytren  (M.  le  Baron.)  Lecons  Orales  de  Clinigue  Chi/rurg- 

icale   tome  III.   p.  663.    'id.  Edit.     Also,    Journal  Ilel- 

domadaire  de  Medicine  de  Paris.     Annee  1829.    tojue  II. 

p.  421, 
Duret  (    )  Recueil  Periodique  de  la  Societe  de  Medi<iine  de 

Paris,   tome  IV.  p.  4:0.    Also,  These  Inaugurale  de  Miriel- 

jeune.     Paris :  1835. 


INTUODUCTION.  25 

DuiT  (George  Tubie.)  Miscellanea  euriosa.  she  ephem.  acad. 
natui'  curlosor  decur.  II.  ann.   VI.  ohser.  62.  j';.  3.    1GG8. 

E. 

Edwards  (D.  O.)  London  Lancet.  Vol.  I.  p.  637.  Febru- 
ary, 1830. 

Eno-el  ( II.  T.)  Dissertatio  de  Utero  deficiente.  apud.  Schlegel, 
tome  I.  ^.259. 

Eno-erriiii  (  )  Me  moire  de  V  Academic  Roy  ale  de  Chirurgie  de 
Paris.     Annee  17S1.     tome  II.  p.  253. 

Ericlisen  (John.)  The  Science  and  Art  of  Surgery.  Chap. 
L  V.  p.  856.     London  :  1857. 

Estero  (    )  Instit.  Chlrurg.  tome  II.  sec.  V.  cap.  163.  Wo.  1. 

E. 

Fabricius  (Guilhelmus,  of  Ilildanus.)  Ohservationum  et  Gura- 
tionum  Chirurgicarum  CenUtria.  centur.  I  ohserv.  73  et 
75. 7;.  54.  Basil:  1606.  Folia. 

Fabricius  (Hieronymus,  ab  Aqiiapendente.)  Opera  Chirurgi- 
ca.  par.  I.  cap.  88.     Patav  :  1617.     Folia. 

Eenerly  (  )  Gazette  des  Ilopitaux  de  Paris.  Annee  1857. 
N'o.  XGVIII  p.  391.  From  Gazette  Medicate  d' Orient. 

Fero-ussoii  (William.)  Edinburgh  Medical  and  Surgical 
Journal.  Vol.  XXXVL  p.  363.  1831.  Also,  A  System 
of  Practical  Surgery,  ith  Amer.  Edit.  p.  515.  Philadel- 
phia: 1853. 

Fitteau  (     )  Sedillot    Recueil  Periodique.  tome  II.  p.  101. 

Flachs  (  )  Dissertatio  de  Atresia  Ani  Congenita.  Lipsioi: 
1831. 

Flaj ani  (Giuseppe.)  Collesione  d' Osservazioni  e  Riflessione 
di  Chirurgia.     tome  IV.' osserv.  S9.    Roma:  1798 — 1803. 

Fleischmann  (S.)  Pe  Vitus  congenitis  circa  Thoracem  et  Ab- 
domen. Toh.  IV.    Erlangce :  1810.  Uo. 

Ford  (Edward.)  Medical  Facts  and  Observations.  Vol.  I. 
p.  102.     London:  1791. 


26  INTRODUCTION. 

Forget  (C.  P.)  Revue  Medicale  de  Paris.  3fai,  1835.  2>-  283. 

Also,  Union  Medicale  de  Paris.  Annee  1850. 
Foucart  (     )    Gazette   des  Tlojpitaux  de  Paris.    Fevrier  21, 

1857.  J^o.  XXI.  p.  86.     From  La  Franc  Medicale. 
Fourcade    (    )     Revue    Medicale  de  Paris.     Annee   1830. 

tome  IV.  p.  52. 
Fournier  (M.)   Pictionnaire  des  /Sciences  Medicales  de  Paris. 

tome  lY.  p.  155. 
Freer  (George.)    London  Medical   and    Physical    Journal. 

Vol.  XL  V.  p.  9. 
Friedberg  (Hermann.)  Reclierches  Cliniques  et  Critiques  Sur 

PAnus  Artijlciel.     In  Archives  Generates  de  Medicine  de 

Paris.  Annee  1857.  Nos.  Mai.,  Jain,  et  Juillet. 
Fristo   (    )    Mott's   Velpeau.      Vol.   III.   p.  1086.      I^ew- 

rorh:  1847. 
Fiirst  (    )  Miscellanea  ouriosa  sive  ephem.    acad.    natur  curi- 

osor.  decur.  II.  ann.  Ill  ohserv.  112. 

G. 

Gay  (G.  H.)  Records  of  the  Boston  Society  for  Medical  Im- 
provement.   Vol.  III.  p.  156.  Boston  :  1859. 

Geiring  (    )   Sel.  Med.  Francof.     tome  IV.  p.  137. 

Gilman  (Noali.)  Boston  Medical  and  Surgical  Journal. 
Vol.  XLIX.  p.  115.     Boston:  1853. 

Goescliler  (  )  Vierteljahrschriftfur  die  praTctische  Ilell- 
Tcunde.  XII  Jahrgang.  1855.     Band  III   S.  131.  Prag. 

Goyraud  (  )  Journal  Hebdomadaire  des  Progress  des  Scien- 
ces et  Institutions  Medicales.  tome  III.  p.  245.  Paris  : 
1834. 

Green  (W.  A.)  Southern  Medical  and  Swgical  Journal. 
Augusta,  Ga. :  1858. 

Grimaud  (J.  C.  M.  de.)  Journal  Generale  de  Medicine, 
tome  XXIV.  p.  238. 


INTRODUCTION. 


27 


Gross  (Samuel  D.)     A  System  of  Surgery.      Vol.  I  J.     Chap, 

XIII.  p.  703.     rhiladdphia  :  1859. 
Guersant  (     )  Gazette  des  Ilopitaux  de  Paris.  Juin  16,  1857. 

No.  70.  p.  277. 

H. 

Ilaesbert  (    )    Miscellanea  curiosa  sive  ep/iem.     acad.    natur 

curiosor.     decur.  II.  ann.  X.  observ.  75.  p.  132.     1001. 
Haly  (Abbas.)    Prad.  Lib.  IX.  c.  63. 
Hartmann  (Philippus.)  Miscellanea  curiosa  sive  ephem.    acad. 

natur  curiosor.  decur.  II  ann.  1691.  jy.  279. 
Ilassebnann  (J.  G.)  Pe  ani  intesthm'umque  atresiae.   Utrecht : 

1819. 
Hays  (Isaac.)  American  Cyclopcedia  of  Practical  Medicine 

and  Surgery.      Vol.  II     Art.  Imperforate  Anus.    p.  151. 

Philadelphia :  1811. 
Play  ward  (George.)    The    Virginia    Medical    and    Surgical 

Journal.     Vol.  I.   p.  268.  Richmond:  1853.     Also.,  The 

American  Journal  of  the  Medical  Sciences.      Vol.  XXVI. 

N.  S.  p.  554.     Philadelphia :  1853. 
Heister  (Laurence.)  Institutiones  Chirurgie.      Part  II.  Sec. 

V  Chap.  CIXIIL  Amstelaedami :  1739. 
Henkel  (J.  F.)  Mem.  Med.  Chirurg.  AmnerTcungen.  II.  1772. 
Iligginson  (F.)  Boston  Medical  and  Surgical  Journcd.     Vol. 

I  VII  p.  238.     Boston  :  1857. 
Hill  (Thomas  P.)    Boston  Medical    and    Surgical    Journal. 

Vol.  XXI  p.  320.     Boston:  1839. 
Hochstetter  (C.  F.)    Med.    WocJmiblatt.    Xo.  18,  1780,    and 

Xo.  19.  1783. 
Hoffman  (Richard  K.)  Xew  Yorh  Journal  of  Medicine  and 

Surgery,     Xo.  III.   January.,  1840.  p.  212. 
Holtzach  (    )  Schenckii.  Ohservationum  Medicarutn  rarariim 

novarum  admircdjilium  et  monstrosaruin.     Lih.  Ill    Sect. 

I.  olserv.  227.  p.  387.    Francof :  1609.    Folia. 


28  DrTEODrcnox. 

Hougliton  (L.  ^.)    Boston  Medical  and  Surgical  Journal. 

Vol.  XXX  YL  p.  520.  Bodon :  1S47. 
Howsliip  Mohn)     Practical    Observations    in    Surgery   and 

2£orhid.  Auatomy.    p.  316.     London  :  1S16. 
Huber  (A.)  Acta  Physico-Medica.     tome  Till.   Ohserv.  24. 

p.  oi.     Xoriniberg. 
Hutchison  (Alexander  Copeland.)  Practical  Observations  in 

Surgery.   M  Edit.  p.  ^oQ.  London:  1S26. 

J. 

Jamieson  (James.)  Edinburgh  Medical  Essays  and  Observor 
tions.     Vol.  IV.  Art.  XXXIL  j?.  354.  1771. 

Jacquemin  (    )  Pevue  JLedicale  ds  Paris.  Mai,  1835.  p.  286. 

Jessen  (Johan  i  ScheuckiL  Observationum  Medicarum,  rarar- 
um  adrnirahlilium  et  inonstrosarurn.  Lib.  III.  observ.  V. 
Francf.:  1609.     Folia. 

Johnson  (W.  Otis.}  Records  of  ths  Boston  Society  for  Medi- 
cal Irnproveraent.      Vol.  III.  p.  214.     Boston :  1859. 

Jolliet  (  )  Journal  de  Medicine,  Chirurgie,  Pharmacie  par 
Leroux,  <&c.     tome  XXXII.  p.  272. 

Jones  (George  Stephens.)  Boston  Medical  and  Surgical 
Journal.      Vol,  L  VII.  p.  203.  Boston  :  1S57. 

Jones  (James.j  Xew  Orleans  Medical  and  Surgical  Journal. 
Vol.  XV.  p.  98.  1858. 

Jourdan  (A.  J.  L.)  Dictionnaire  ahrege  dcs  Sciences  Medi- 
cales.     tome  XL   p>.  237. 

Journal  des  Savants,  pour  Vannee  lll'i. 

K. 

Kaltschmeidt  (Carl  Frid.  j  Dissertatio  de  raro  casu  vbi  intestin 
rectum,  in  vesca  urin,  insertum  fuit.     Jena  :  1756. 

Kii^ten  (    )  Act  nat.  cur.  lib.  IX.  observ.  XI.  p.  24. 

Klein  (Christian.)  Xova  Ada  Acadernie  Xaturce  Curiosum. 
ann.  I.  obs.  38. 

Klewitz  (    )    Gazette  Medicate  de  Berlin.  April  29,  1835. 


INTKODUCTIDX.  29 

Kretsclimar  (     )    Ilorti's  Archivfiu'  die  Medicinsche  Erfah- 
rung.     Band  I.  II.  TIT.    349. 

L. 

Lacoste  (    )   Bulletin  de  la  Societe  Medicale  (T Emulation  de 

Paris.     Odohre,  1822.  ;p.  417. 
Liiper  (    )    De  vitiis  fabrics  pHniitivcB  intestini  recti  et  orifi- 

eil  ani.      These  inaugurale  de  Wurtzhurg.     1S26. 
Latta  (James.)  Practical  System  of  Surgery.      Vol.  II.  Chap. 

VII.  p.  84.     Edi)d)urgh  :  1795. 
Lauremberg  (    )  Procrest  Anat.     Lib.  I.  cap.  16. 
Leveille  (    )  Desault.  Journal      Chirurgi^.    tome  I V. 
Leveille  (J.  B.)    Rapport  des  Travaux  de  la  Societe  Philom. 

tome  I.  p.  145. 
Levret  (M.  Andrew.)  VArt  d^s  Accouchemens,  de  montre  par 

des  Principes  de  Physique  et  de  Mechan-ique.     Paris: 

1761. 
Licetiis     (Fortimius.)     Be  Jlonstrorum    Causis    JTafurw  et 

differentus.     Lih.  II.  cap.  53.     Patavia  :  1616.     4:to. 
Lieutaiid  (     )  Bulletin  de  l<i  Societe  Anat   de  Paris.     Jlai, 

1839.  p.  86. 
Littre  (    )    Memoire   de  VAcademie   Boyale  des  Scieiices  de 

Paris.     Annee  1709.  p.  9.     Also,    Histoire  de  VAcademie 

des  Sciences.     Anjiee  1710.  p.  36. 
Lolirer  (    )  Constatfs  Jahresber filr.  1842.  Band  I.  S.  456. 
Louis  (    )    Theses  Anatomicw  Chi rurgie.  Paris:  1754. 
Lucas  (Bennett.)  Costello.  Cycl-opcedia  of  Practical  Surgery. 

Vol.  I.  p>-  472.  London  :  1841. 
Ludovicus  (     )  JTiscellanea  curiosa  sive  ephein.    acad.   natur 

curiosor.  decur.  I.  ann.  III.  obs.  257. 

:m:. 

Malgaigne  (J.  F.  )  Operative  Surgery.     Chap.  YIII.  p.  444. 

Brittan's  English  Version.     Philadelphia     1851. 
Malyn  (John.)  Costello.     Cyclopcedia  of  Practical   Surgery. 

Vol.  I.   Art.  Anu.s.  p.  331.     London  :  1841. 


30  INTRODUCTION. 

Mantell  (T.)    Memoirs  of  the  Medical  Society    of   London. 

Vol.  III.  Art.  XIX.  p.  389.  London :  1792, 
Matani    (Ant.)      OrtesJd  Giornal   di  Medicini.      tome  III. 

p.  250.   Padoue. 
Martin  (de  Lyon.)  Dict'wnnaire  des  Scie'nces  Medicales.   tome 

XXIV.  2^-  127.     Also,  Acta  de  la  /SocietS  de  Lyon. 
Martin  (    )    Annates  de  Societe  Natur.  tome  XII. 
McEvoy  (Francis.)  London  Lancet.      Vol.  IV.  p.  568.     De- 

cember,  1846. 
Meckel  (J.  F.)  ReiVs  ArchivfiXr  die  Physiologie.  Band  IX. 

II.  1.      Also,    Handhucli  der  Pathologischen    Anatomic. 

Halle:  1812. 
Memoires  de  I'Academie  des  Sciences.     AnnSe  1752.  p.  113. 
Memoires  de  Berlin.     Annee  1774. 
Mercurialis  (Hieronymus.)  De  MorVis  Pueroriim.    Lihri.  I. 

a  9.      Venetii :  1783. 
Merriman  (Samuel.)  Howship.  Practical  Observations  in  Sur- 

gei'y  and  Morbid  A7iatomy.  _p.  320.     London:  1816. 
Mery    (Jean.)    Histoire  de   V Academic  Royale  des  Sciences. 

An7iee  1700.  j>.  40. 
Miller  (    )    Edinburgh  Medical  and  Surgical  Journal.     No. 

XCVIIL  p.  62.  1829. 
Miriel  (Senieur.)    These    inaugurale   de    Miriel,   la   Jeune. 

Paris:  1835. 
Miriel  (Jeune.)  These  Inaugurale  de  Paris.    Annee  1835. 
Mitchell   (John  S.)     Charleston   Medical  Journal.      Vol.   V. 

p.  752.     1850. 
Mitchell  (S.)  Boston  Medical  and  Surgical  Journal.      Vol. 

XLIV.  p.  376.     Boston:  1851. 
Monad  (     )    Nouvelle   Bibliothcque  Medicale.      torne.  II.  p. 

447.     Paris:  1829. 
Monclat  (    )  Nouvelle  Bibliotheque  Medicale.  tome  LT.  p.  99. 
Monro  (Alexander,  Junr )  The  Morbid  Anatomy  of  the   Hu- 
man Gullet,  Stomach  and  Intestines.      Chap.  IV.    p.  542. 

Edinburgh  .-1811. 


INTRODUCTION.  31 

Moiitgoinory  (W.  F.)  Cijclojmdia  of  Anatomy  and  Vhysivlo- 
gy.  By  Rohert  Todd.,  M.  I).  Art.  Foetus,  p.  336.  London  : 
1837. 

Moore  (E.  13.)  Boston  Medical  and  Surgical  Journal.  Vol. 
L  VIL  p.  5U>.     Boston  :  1858. 

Mortiiid  (  )  Ifenioire  de  V Academic  des  Science  de  Paris. 
Annee  1785.  j).  50. 

Morccaii  (J.  L.)  Gazette  Medicale  de  Paris.   Jain  28,  1834. 

Morgagni  (Joan  Bapt.)  De  Sedihus  et  Causis  3forhorum  per 
Anatomen  indagatls.  Libri.  III.  Epist.  XXXII.  Vene- 
tils :  1761.     Folia. 

Murray  (Adam.)  Dissertatio  Atresia  Ani  Vesicalis  singulari 
observatione  illustrata.      XJpsal :  1794. 

Miitter  (T.  D.)  A  Treatise  on  the  Diseases  and  Special  Hy- 
giene of  Females.  By  Colomhat  De  Flsere.  Translated 
from  the  French  hy  Charles  D.  Meigs,  M.  D,  p.  116. 
Philadelphia :  1845. 

Nagel  (  )  Friedherg.  Recherches  Cliniques  et  Oritiqiies  sur 
VAnus  Artificiel.  In  Archives  Generates  de  Medicine  de 
Paris.     Annee  1857.     p.  580. 

Nelaton  (M.)  Clinical  Lectures  on  Surgery.  From  Notes 
taken  hy  W.  F.  Atlee,  M.  D.  Chap.  XIX.  p.  588.  Phil- 
adelphia :  1855. 

O. 

O'Beirne  (James.)  New  Views  of  the  Process  of  Defecation. 

DitUin:   1833. 
Oberteufer  (     )  Neues  Archiv  de  Starh.     tome  II. 
Olinet  (    )    Journal     TJniversel    des    Sciences  Medicales  de 

Paris.     Fevrier  20,  1820. 
Orfila  (M.P.)  Medicine  Legale,  tome  I. p.  150.  Paris:  1821. 
Osiander  (    )  Denwilrdichkeiten.     Band  II.  S.  470. 
Osterdyke  (     )  Papendorf.     op  cit. 


32  INTRODUCTION. 

Ottinger  (     )    These  maugurale  su?'   les  Imperforations   de 

rAnus.     Munich:  1826. 
Otto  (    )    Pathologische  Anatomie.     Breslau  :  1813. 
Oiivrard  (    )  *Lancette  Francaue.    tome  II.   j^-  99.     Paris : 

1837. 


Page  (C.  G.)  Boston  Medical  and'  Surgical  Journal.      Vol. 
I  VII.  p.  239.     Boston  :  1857. 

Palmer  (     )  Medico- Chirurgical  Journal.    Vol.1.     london  : 
1816. 

Pancoast  (Josepli.)     Operative  Surgery,     p.    296.     Philadel- 
phia:  1844. 

Papendorf  (    )    Pissertatio   sistens  Ohservationes  de  ano  in- 
fantum  imperforato.  Lugd.  Batav  :  1781.    Also,  Abhand- 
lung  von  der  angehohrneti    Verschliessung  des  Afters  hey 
Kindren.     leipzig :  1783. 

Parkirian  (S.)  Records  of  the  Boston  Society  for  Medical  hn 
provement.    Vol.  II.  p.  54.     Boston  :  1856. 

Parrisli  (Joseph.)    Medical    Recorder.       Vol.    VII.   p.  359. 
Ph'daddphia  :  1824. 

Panli  (^ginetse.)  lihri  Septem.  Greek  et  Latin.  Lib.  VL 
cap.  81.  Basilce :  1532.  Folia. 

Petermann  (And.)  Ohservationes  Medicm.  dec.  II.  ohserv.  2. 
lijjsm:  1707. 

Petit  (Jean  Louis.)  Remarqnes  snr  les  difFerens  Yices  de  con- 
formations que  les  enfans  apportent  en  naissant.  Memoires 
de  TAcademie  Roval  de  Cliirurgie  de  Paris.  Annee  1781. 
tome  II. 

Pikcop  (John.)  London  Lancet.    Vol.  I.  p.  510.  May,  1850. 

Pillore  (  )  Actes  de  la  Societe  de  Lyon.  Annee  1797. 
p).  189. 

Pineo  (P.)  Boston  Medical  and  Surgical  Journal.  Vol. 
L  VII.  p.  284.     Boston  :  1858. 


INTUODUCTION.  33 

Pinkstau  (  )  A  Cullectloii  of  I*r<icrnaiural  Canck  and  Oh- 
seroatloas.  Bij  W.  SitielUe,  M.  D.  Vol.  111.  Collect. 
XL  VI.  p.  40 J:.     London  :   1799. 

Portal  (M.)  Freds  de  Chirurgie  I^ratique.  tome  II.  />.  Y45. 
Pans:  1768. 

Poulletier  (     )  Dietlonnaire  des  Sciences  Medlcales  de  Paris. 

tome  IV.   p.  157 

K. 

Kiindolplie  (    )    Encyclopcedie    des    Sciences    Medlcales    de 

Paris.  Annee  1839.  p.  195. 
Eiclierand  (A.iitli.)    Nosographie  Chirurgicale.     tome  III.  p. 

437.   Qualricine  Edit.    Paris:  1812. 
E-icliardson  (     )    Philosophical  Transactions  of  the  Royal 

Society  of  London.    Vol.   VII. 
Eichter  (A.  G.)  Chirurgische  Bihliotheh.   Gottimgens :  1774. 
Ricord  (Philip.)    Journal    Universel      et    Hebdomadaire   de 

Mediciui^.,  ii^c.     tome  XII.  p.  167  Paris.      Octohre,  1833. 
Pochard  (    )   Journal  de  Medicine.,    Chirurgie.,   Pltarmacie, 

c&c.     tome  LXXXV.  p.  370. 
Koestel  (    )  Mursin7ia'' s  Journal   der  Chirurgie.      Band  I. 

S.  547. 
Poonhuysen  (Henry  Yan.)  Medico-Ghirurgical  Ohservations, 

c&c.  English  Versio7i.  Part II.  Observation'^.  London:  1676. 
Possi  (    )  Ilidoire  de  la  Societe  de  Medicine  de  Montpellier 

tome  I.  p.  39. 
Roux  (J.  N.)  (de  Brignoles.)  Gazette  Medicate  de  Paris.  Juin 

28,  1834. 
Pust  (Johan  N.)  Theoretisch-praktisches  Handhuch  der  Chir- 
urgie.    Berlin:  1830.     Also.,  Magazin  fur  die  Gesammte 

Ilcilk'itnde.     Berlin. 
Piiysch  (H.)    Adversaria  Anatomica.  decad.  II.  c.  10.  j9.  43. 

S. 
Sabatier  (P.  B.)    Be  la  Medicine  Operatoire.     tome  IV.   p. 

244.    Nouvelle  Edit.    Paris:  1824. 
Saiiit-Hilaire  (Le  Chevalier  Geoffroy.)    Histoire    Generate  et 

ParticuUere  des  Anomalies  de  Organization  chez  V Homme 

et  les  Atiimaux.     Bruxelles  :  1837. 


34  INTRODUCTiaTSr. 

Saint-Hilaire  (Isodore  Geoffrey.)  TraitS  de  Tcratologie. 
Paris:  1832. 

Sanden  (Van.)  Miscellanea  curiosa  sive  e^hemer.  acad.  natui' 
curiosor.  decur.  ann.  IX.  X.  ohserv.  194.  p.  364.     1706. 

Sandras  (     )  Revue  Medicals  de  Paris.  Mai.,  1835.  p.  285. 

Saviard  (Bartholomew.)  Nouveau  Recueil  d'' Observations 
Chirurgicales.     Ohs.  III.  et  XGIV.     Paris  :  1702. 

Sclienckiiis  (John,)  (of  Graifenberg.)  Ohserv ationum.  Medicar- 
uin  et  Chirurgicarum,  Rararutn  JSfovarum^  Adrniralilium, 
et  Monstrosarum.  Libri  IV.  Obs.  24.  Prihurgl  Bris- 
gavice :    1597.     Folia. 

ScUagintweit  (Wilh.  Aug.  Josepli.)  la  These  inaugiirale  de 
Ottinger.)  sur  les  Imperf orations  de  Vanus.  Munich  :  1826. 

Schleiss  (Von.)  ZeitscJirlft  fur  Rationell  Medicin.  Neue 
Folge.     Band  III.  S.  366.     Ileidelburg  :  1853. 

Schiiltz  ,(  )  Jliscellanea  curiosa  sive  ephem.  acad.  natur  cu- 
riosor.    decur.  I.  ann.  III.  obs.  2.  p.  5. 

Scultetus  (Joannes.)  Ai'mamentariura  Chirurgicum.  Obser- 
vatio.  LXXVII.  p.  323.     Amstelcedami  :  1741. 

Seaverns  (  )  Records  of  the  Boston  Society  for  Medical  Im- 
provement.     Vol.  III.  p. 'il^.     Boston:  1859. 

Serrand  (de  St.  Malo.)  These  inaugurate  de  Montpellier.  1814. 

Serres  (E.)  Recherches  W  Anatomie  transcendante  et  Patholog- 
ique  /  theorie  des  formations  et  des  deformations  organiques^ 
appliquee  a  Vanatoinie  de  la  duplicite  monstrueuse. 
Paris:  1832. 

Shipman  (A.  B.)  Boston  Medical  and  Surgical  Journal.  Vol. 
XXXIII.  p.  210.     Boston  :  1840. 

Smellie  (William.)  A  Collection  of  Preternatural  Cases  and 
Observations  in  Midwifery.       Vol.  III.     Collect.  XL  VI. 
p.  461.     London  :  1779. 

Smith  (Ashbell.)  Amsrican  Journal  of  the  Medical  Sciences. 
No.  XXXIV.  p.  341.  February,  1836.  Philadelphia. 

Smith  (J.  A.)  Dorsey.  Elements  of  Surgery.  Vol.  II.  Chap. 
LXIV.  p.  469.  M  Edit.  Philadelphia:  1823.  From  New 
York  Medical  and  Phdosophical  Journal.    Vol.  II. 

Smith  (W.  G.)  London  Lancet.     Vol.  IV.  p.  125.  1846. 


INTKOhUUTION.  85 

Smith  (lieiiry  11.)    A  SyHeni  of  Operative  Surgery.     Vol.  IL 

/?.  331.  "i^d  Edit.  Pkiladelplua :  185G. 
Soinmering  (Samuel  Thorn.)  Ahildimgen  und  Beschreihungen 

einigcr  Misgeburten.     Mainz  :   1791.  S.  53.    Folia. 
Soranus  (of  Ephesus.)   164. 
South  (John  F.)     Saint  TJiomas    Hospital  Reports,   p.  121. 

London ;  1836. 
Steel  (Jolin  H.)  American  Journal  of  the  Medical  Sciences. 

Ho.  XXX.  p.  404.  Fehruary,  1835.  Philadelphia. 
Stewart  (James.)  A  Treatise  on  the  Diseases  of  Infants.  By 

C,  M.  Billard.     English  Translation    hy    James  Stewart. 

M.  D.    p.  577.     Ntw  York:  1839. 
Surgeon  of  Brest.    These  Inaiigurale  de  ^errand  de  Montpel- 

Her.  1814. 
Surgeon  of  Lyons.   TJwse  Inaugurate  de  Serrand  de  Montpel- 

lier.  1814. 
Switzer  (Erico.)  Annotationes  in  colotomiam.  Ilafnim :  1827. 

T. 
Teale   (T.    P.)  Costello.     Cyclopmdia  of  Practical  Surgery. 

Vol.  II  p.  213.     London:  1841. 
Textor  (K.)  Laper.  De  vitus  fabriccB  primitivm  intestini  recti 

orificil  ani.     These  inaugurate  de  Wurtzbourg.     1826. 
Tiedemann  (     )  London  Medical  and  Physical  Journal.  July., 

1826.    Also,   Edinburgh   Medical   and  Surgical  Journal. 

January,  1829. 
Townsend  (     )  Records  of   the   Boston  Society  for  Medical 

Improvement.      Vol  II.  p.  M.     Boston  :  1856. 
Trioen  (Cornel.)    Observationum  Medico-Chirurgicarum.    p. 

60.     Lugd.  Batav :  1743. 
Tiingel  (C.)    Uber  Kunsiliche  Afterbildang.     Kiel :  1853. 

V. 
Vallesnieri  (Ant.)    Dictionnaire    des    Sciences  Medicates  de 

Paris,     tome  lY. 
Van  Meeckren  (Jobi  a.)     Observationes    Medico-Chirurgicoe. 

cap.  XXI Y.  p.  114.     AmsUlcedami:  1682. 
Van  Swieten  (Ger.  F.  B.)   Com.mentaria  in  Hermanni  Boer- 

haave  Aphorism.os  de  cognoscendis  et  curandis  Morbis.  Lib. 

lY.  Aphorism..  1340.  p.  575.  Lnqd,  Batav  :  1785. 


36  INTKODUCTION. 

Velpeau   (Alf.  A.  L.  M.)   Houveaux  Eleinenis   de  Medicine 

OperatoiTe.     Z  torn,  tt  atlas.     Paris:  1832. 
Yicq  d'Azyr.    EncyclopcBdie  Methodique  Med.  Anat.  Pathol, 

Voigtel  (F.  G.)    Ilandhuch    der    Pathologischen    Anatomiey 

Band.  II.  /S'.  6il.     Halle :  1804. 
Voisin  (F.)   Reciieil  Periodiqiie  de  la  Societe  de  Medicine  de 

Paris,    tome  XXI.  jp.  353.     Also.,  Fine^s  Memoire  in  Aiv- 

nales  de  la  Societe  de  Medicine  de  Monijpellier.    tome  VI. 
Voilleiiiier  (    )  Gazette  des  Hopitaux  de  Paris.    AnnSe  1846. 
Vollgnad  (  )  Miscellanea natur  curiosa.  decur.  I.  ann.  I.  6b.^. 
Vrolik  (    )  3Iem.  sur  qudques  sujets  d'Anat.  et  de  Phys.  p. 

22.     Amsterdam:  1822. 

W. 

Wagner  (Peter  Cliristoplier.)  Comnier.  Litter ar.  p>.  364. 
Xorimherg :  1734. 

Waters  (  )  The  Duhlin  Journal  of  Medical  Science.  Vol. 
XXI  p.  321.     1842. 

Wandermonde  (  )  Pecueil  Periodique  de  la  Societe  de  Med- 
icine de  Paris,     tome  VI.  p.  128. 

Wayte  (John.)  Edinburgh   Medical   and  Surgical   Journal. 
Vol.  XVII    j9.  232.     April,  1821. 

West  /'Charles.)  Lectures  on  the  Diseases  of  Infancy  and, 
Childhood.  Lecture  XXXI.  jp.  374.  2^  Amer.  Edit. 
Philadelphia:  1864, 

Willaume  (    )  Journal  des  Progress,     tome  VIII  p,  238. 

Williams  (  )  Eemie  Medicale  de  Paris.  Annee  1826.  tome 
III  p.  170. 

Wolf  (C.  F.)  Langenbeck.  Xeite  BiUiothehfilr  die  Chirurgie 
und  Ophthalmologie.  Band.  Ill  S.  231.    Hanover. 

Wreisberg  (Henry  Aug.)  Dissertatio  de  preter natur ali  et  raro 
InUstini  Recti  cum  Vesica  Urinaria,  Coaliiii.,  et  indepen- 
dente  Ani  Defectu.  Gottmgen :  1779.  Also,  Comrnenta- 
tionum  Medici.,  Physiologici,  Anatomici  et  Ohstetrici  Ar- 
gumenti.  p.  172.  Tab.  VII.     Gotting. :  1800. 

Y. 

York  (J.  H.)  Boston  Medical  and  Surgical  Journal.  Vol. 
XLlIp.^n.     Boston:  V^h^. 

Z. 
Zacntiis  (Lnsitanus.)  Prax.  Med.  Admir.  Libri  III.  observ.  72. 


SECTIOK    II. 

GENERAL   REMARKS. 

The  rectum  and  its  teriniiuil  ap})aratus,  the  anus,  like  other 
portions  of  the  organization,  are  liable  to  malformations  and 
imperfections,  the  result  of  some  extraordinary  derangement 
of  the  acts  of  the  plastic  energies  at  some  period  during  the 
evolution  of  the  embryo  or  the  foetus  in  utero. 

From  the  remotest  antiquity  the  congenital  closure  of  the 
anus  or  the  rectum  was  noticed  by  the  Greek,  the  Roman  and 
the  Arabic  physicians.  They  however  looked  upon  it  gener- 
ally as  beyond  the  power  of  art  to  remedy,  and  consequently 
as  possessing  no  interest  in  their  estimation  beyond  that  of  a 
lusus  natui'CB. 

These  congenital  vices  of  structure  have  been  designated 

by  the  terms — 

Lnperforate  Alius. — English. 

Imperforatio.  ] 

Atresia  Ani,   v  Latin. 

Clausitra.        ) 

Imperf oration  De  V Anus.  \      -p,      -j 
Impeiforation  Du  Rectum.  \ 

Yerschliessung  Des  Mastdarmes. — German. 

There  is  however  a  manifest  impropriety  in  the  application 
of  some  of  these  terms  to  many  of  the  malformations  of  these 
parts.  Under  the  generic  term — Imperforate  A  mis,  malform- 
ations of  the  anus  and  the  rectum  are  included  which  differ 
essentially  from  each  other,  with  regard  to  situation,  form, 
cause  and  result.  It  is  therefore  imj^roper  to  denominate  a 
case  imperforate  anus,  in  which  the  anus  itself  is  pervious, 
although  otherwise  malformed ;  or  in  wliich  the  anus  is  per- 
fectly natural,  the  deformity  or  imperforation  being  in  the 
rectum,  more  or  less  distant  above  the  normal   anus ;    or   in 

which  there  is  an  entire  absence  of  the  anus.      Each   one   of 
[37] 


38  INTKODUCTION. 

these  terms  is  too  exclusive  in  its  signification  to  embrace  all 
the  malformations  of  these  organs,  or  to  be  used  as  a  generic 
term  in  relation  to  them,  consequently  not  one  of  them  can 
ever  be  so  used  with  propriety. 

Some  of  these  vices  of  conformation  are  by  no  means  un- 
common, and   all   of  tliem   are  in  a  practical  point  of  view, 
more  or  less  important.     Many  of  them  are  remediable,  and 
as  they  generally  admit  of  no  delay  in  their   treatment,  but 
demand  prompt  means  for  their  relief,  a  knowledge  of  all  the 
medical  and  surgical  measures  which  experience  has  decided 
to  be  best  adapted  to  remedy  each  particular  deformity,  is  of 
the  utmost  importance  to  every  surgeon  and  accoucheur.     In 
the  absence  of  such  knowledge  no  practitioner  in  this  respect 
is  able  to  discharge  his  professional  duties  with  satisfaction  to 
the  public,  or  with  an  easy  conscience  to  himself.      In  these 
instances  nothing  can  be  expected  from  any  efforts  of  nature 
towards  eflecting  any  substantial  relief.     If  no   operation   is 
undertaken,  death  must  soon  follow  from  necessity.     Nothing 
will  avail  but  some  surgical  interference,   for  Nature  has  not 
dealt  with  the  human  species  as  she  has  with  some  of  the  in- 
sect tribes,  for  instance  the  ant^  which  according   to   the   ob- 
servations of  the  great  natural  historian  Keaumur,  has  neither 
an  anus  nor  any  intestinal   excrements  that  can  be  perceived. 
{Memoire  pour  Vllist.  des  Insect,  tome  vi.  Mem.  10.) 

No  accoucheur  should  ever  neglect  the  important  duty  of 
examining  minutely  every  infant  immediately  after  its  birth, 
and  for  a  day  or  two  subsequently,  to  ascertain  without  a 
doubt  that  there  is  an  anal  aperture,  that  the  canal  for  some 
distance  above  is  pervious,  and  that  the  parts  perform  their 
normal  functions.  Tliis  important  duty  is  too  often  neglected 
by  persons  engaged  in  the  practice  of  midwifery.  Tliere  is 
one  thing,  however,  that  is  scarcely  ever  neglected,  especially 
by  female  accoucheurs  and  monthly  nurses,  and  that  is  the 
pernicious  practice  of  thoroughly  purging  new-born  infants, 
irrespective  of  circumstances.      One  of  the   pleas  set  up  for 


INTKODUCTION.  39 

admin isteriug  the  v;iri(»iis  nauseating-  clniuglits  to  which  new- 
born children  are  subjected,  is  tlie  great  dread  in  southern 
climates  of  trismus  nascentiwm  /  the  popular  and  erroneous 
idea  being  that  trismus  is  the  necessary  result  of  retained  me- 
conium. This  practice  is  especially  pernicious  in  cases  in 
which  there  is  a  permanent  obstruction  in  the  lower  bowel 
from  malformation.  In  such  cases  it  is  obvious  that  purgative 
medicine  would  prove  not  only  useless,  but  highly  injurious  ; 
indeed  physic  or  improper  food  either  would  only  induce  pa- 
roxysms of  pain  and  vomiting,  and  hasten  the  fatal  result. — 
Tlic  little  sufferer  thus  often  falls  a  victim,  either  to  ignorance 
or  to  a  false  philanthropy.  It  would  be  far  better  and  much 
more  humane  to  suffer  such  patients  to  die  slowly  of  inani- 
tion, than  to  torture  them  to  death  rapidly  by  the  free  use  of 
improper  food  or  medicine.  In  hopeless  cases,  if  absolute 
diet  is  enjoined,  it  is  surprising  how  long  the  little  patients 
will  survive  apparently  with  but  little  suffering  before  they 
succumb  to  the  effects  of  inanition.  Professor  Dewees  men- 
tions two  cases  in  point,  "  Dr.  Hallam  delivered  a  patient 
of  a  fine  muscular,  fat  and  healthy  child,  which  had  an  im- 
pervious oesophagus,  so  that  no  food  ever  passed  into  the  sto- 
mach. The  child  lived  thirteen  days,  but  was  so  wasted  that 
its  skin  hung  like  a  loose  garment,  and  could  be  lapped  and 
folded  over  its  limbs."  In  another  instance  says  Dr.  Dewees, 
"  a  child  was  born  with  every  external  appearance  of  healthy 
conformation,  but  upon  attempting  to  give  it  a  little  molasses 
and  water,  it  had  nearly  strangled.  Upon  looking  into  its 
mouth,  it  was  discovered  that  there  was  no  vault  to  it ;  neither 
was  there  a  vestige  of  soft  pallet.  It  never  swallowed  a  drop 
— ^indeed  every  attempt  w^as  followed  with  such  terrible  dis- 
tress by  the  fluid  passing  into  the  trachea,  that  the  trial  w^as 
abandoned.  It  lived  ten  days — became  extremely  emaciated 
and  very  yellow^"  {A  System  of  Midwifery^  p.  215.  Phil. 
1832.)  Food,  in  all  cases  of  obstruction  of  the  anus  or  the  rec- 
tum from  malformation,  should  be  very  cautiously  adminis- 


40  INTRODUCTION. 

tered.  or  altogether  proscribed,  with  the  exception  of  the  mo- 
ther's milk,  or  a  little  sugar  and  water,  until  the  obstruction 
is  removed  ;  and  if  this  cannot  be  accomplished  and  death  is 
inevitable,  let  this  event  take  place  gradually  by  inanition, 
rather  than  speedily  by  repletion.  Purgative  medicines  in 
all  such  cases  are  entirely  inadmissible ;  although  I  am  aware 
that  some  able  surgeons  advise  them  for  the  pui'pose  of  forc- 
ing down,  if  possible,  the  end  of  the  rectum  preparatory  to 
searching  for  it. 

It  is  generally  believed  that  the  congenital  malformations  of 
these  parts  are  quite  unconmon.  Mr.  AVest  says  that  "  The 
affection  (meaning  imperforate  anus)  in  any  form  is  so  rare  as 
to  render  a  correct  estimate  of  the  comparative  frequency  of 
its  varieties  by  no  means  easy."  {Lectures  on  the  Diseases  of 
L fancy  and  Childhood.,  Amei'ican  Edit.  p.  ^74:.  Phil.  185-t.) 
Mr.  Collins  says  that  he  only  observed  one  instance  of  it  out 
of  16,645  children  born  in  the  Dublin  Lying-in  Hospital,  dur- 
ing his  Mastership.  {System  cf  Midwifery .,  p.  509.)  Dr.  Lohrer 
of  Vienna  says  that  he  met  w^itli  it  only  twice  out  of   50,000 

new-born  children.     {Constatfs  Jaliresber  fur  1842.  Band  I. 

S.  456.) 

Notwithstanding  these  statements,  I  am  of  the  opinion  that 
these  malformations  in  some  form  or  other  are  of  much  more 
frequent  occurrence  than  is  generally  conceded,  and  that  ma- 
ny children  born  with  some  one  or  other  of  them,  are  sufiiered 
to  perish  for  want  of  proper  and  timely  surgical  assistance 
through  either  the  ignorance,  the  neglect,  or  the  mismanage 
inent  of  midwives  and  monthly  nurses,  l^one  doubtless  but 
the  most  desperate  and  the  most  remarkable  cases  are  evei 
reported,  the  rest  being  either  entirely  overlooked,  or  passed 
by  unrecorded.  But  few  cases  appear  to  have  occurred  to 
the  older  surgeons,  in  consequence  no  doubt  of  the  general 
employment  of  ignorant  midwives,  who,  even  if  they  discov- 
ered them,  never  revealed  nor  recorded  them.  These  several 
circumstances  may  account  for  the  paucity  of  information  up- 


INTRODUCTION.  41 

on  tliis  subject  among  the  old,  and  to  some  extent  also  among 
the  modern  surgeons.  It  is  therefore  impossihlc  IVom  the  data 
before  me  to  draw  any  satisfactory  conclusions  on  the  subject. 


SECTION    III. 

ETIOLOGY. 

"With  regard  to  the  primary  cause  which  determines  these 
or  other  congenital  vices  of  conformation,  nothing  of  a  defi- 
nite, or  of  a  satisfactory  character  has  yet  been  ascertained. 
The  science  of  embryology  which  is  now  being  so  successfully 
cultivated,  teaches  that  at  any  period  during  the  evolution  of 
the  embryo  or  the  foetus, the  action  of  the  formative  energies 
in  any  part  of  the  organization,  may  be  so  aifected,  or  so  influ- 
enced, as  to  become  either  partially  or  wholly  suspended,  or 
augmented,  and  result  in  the  production  of  imperfect  or  anom- 
alous organs,  or  in  an  entire  want,  or  non-production  of  them. 
This  is  doubtless  the  source  of  many  of  the  congenital  mal- 
formations observed  in  the  anus  and  the  rectum  ;  but  as  the 
first  or  primary  cause  of  this  disturbance,  or  of  this  interrup- 
tion of  the  plastic  forces,  is  yet  beyond  our  knowledge,  and 
merely  conjectural,  all  in  relation  to  it  therefore,  is  hypoth- 
esis. 

Might  not  the  result  of  power  acting  upon  the  foetus  in 
utero  through  the  imagination,  or  the  feelings  of  the  mother, 
be  the  cause  of  malformations  ?  Is  it  at  all  possible  for  the 
'maternal  imaginatio7i  to  be  so  wrought  upon  as  to  cause  a 
partial  or  a  total  arrest  of  development,  or  an  excess  of  devel- 
opment in  any  portion  of  the  foetus  ?  Will  any  one  deny 
that  a  sudden  fright  of  the  mother  might  not  be  sufficient  to 
destroy  the  life  of  the  foetus?  or  refuse  to  admit  that  vivid 
and  prolonged  impressions  of  the  mother,  of  whatever  cliarac- 


42  INTRODUCTION. 

ter,  miglit  not  give  rise  to  disease  in  the  foetus,  and  such 
disease  ultimate  in  tlie  malformation  of  some  organ  ?  Might 
not  some  of  these  malformations  occur  associated  with  certain 
congenital  and  hereditary  diseases,  in  the  relation  of  cause 
and  effect  ? 

MM.  Serres,  Geoffroy  Saint-IIilaire  and  Eoux  de  Brig- 
noles,  concur  in  opinion  that  the  congenital  malformations  of 
the  anus  and  the  rectum  depend  upon  the  deviation,  the 
imperfection,  or  the  absence  of  the  hfemorrhoidal  arteries. 
Indieed  their  opinion  is  that  the  evolution  of  the  organs  in  the 
foetal  state  proceeds  in  a  strict  ratio  with  their  supply  of 
blood  ;  consequently  that  the  imperfection,  atrophy,  or  absence 
of  the  organs  generally,  is  attributable  to  the  imperfection,  or 
the  absence  of  their  nutrient  arteries. 

According  to  M.  Serres,  the  incomplete  development,  or 
absence  of  a  part  depends  upon  deficient  development  of  the 
artery  which  should  convey  to  it  the  materials  for  its  nutri- 
tion. If  the  artery  is  only  partially  developed,  the  part  to 
which  it  is  distributed  remains  in  a  state  of  atrophy ;  if  it  is 
totally  wanting,  the  organ  does  not  exist.  M.  Beclard  in  com- 
menting upon  this  last  assertion  of  M.  Serres,  says  that  it 
seems  natural  enough  that  the  artery  of  a  part  should  be  want- 
ing, when  the  part  itself  did  not  exist,  and  that  it  seemed 
impossible  for  him  to  decide  which  of  these  two  facts,  the 
absence  of  the  organ,  or  the  absence  of  the  artery,  was  the 
cause  or  the  effect ! 

Tiedemann,  on  the  contrary,  believing  that  the  nervous  sys- 
tem was  developed  before  any  of  the  other  parts  of  the  body, 
was  of  opinion  that  congenital  malformations  or  anomalies 
depend  upon  the  imperfection,  or  the  want  of  certain  portions 
of  the  nervous  system.  He  found  that  whenever  certain  por- 
tions of  the  nervous  system  were  defective  or  missing,  the 
part  to  which  such  nerves  were,  or  would  have  been  distrib- 
uted in  the  normal  state,  was  also  correspondingly  defective 


INTRODUCTION.  43 

or  wanting-.  lie  is  of  opinion  that  tlio  nervous  system  con- 
trols the  Ibrnuition  and  development  ol"  the;  embryo,  and 
determines  the  particular  form  and  disposition  of  the  organs — 
hence  he  concludes  that  most  deformities  have  their  fii-st  cause 
in  the  irregular  development  of  this  system.  (London  Medical 
and  Physical  Journal^  July,  1820.  Also  Edinburgh  Medical 
and  Surgical  Journal,  January,  1829.) 

Tiedemann,  in  my  opinion,  has  by  no  means  proved  clearly, 
as  he  pretends  to  have  done,  that  the  nervous  system  is  devel- 
oped before  the  sanguineous,  that  it  determines  the  particular 
form  and  disposition  of  the  oi'gans,  and  that  its  imperfection 
is  a  first  cause  in  the  production  of  deformities,  &c.  The  evi- 
dences, on  the  contrary,  are  decidedly  in  favor  of  the  view 
taken  by  M.  Serres,  namely,  that  it  is  the  imperfection  of  the 
arterial  system,  -svliich,  in  fact,  exerts  such  powerful  influence 
in  the  production  of  malformations. 

M.  Andral  sets  forth  the  principle  that  whenever  a  part  of 
an  organ  is  imperfectly  formed,  or  found  to  be  partially  or 
wholly  wanting,  those  parts  that  precede  it  in  the  normal  state 
have  themselves  undergone  an  arrest  of  development,  to  a 
greater  or  less  extent.  {Precis  d'' Anatomic  Pathologique, 
tome  1.  p.  109.  Paris :  1829.) 

But  these  highly  distinguished  authors  entirely  fail  to  give 
the  primary  cause  of  these  malformations.  The  question  still 
remains  unanswered ;  and  it  might  still  be  asked  them  too, 
with  propriety — what  is  the  cause  of  the  deviation,  the  imper- 
fection, or  the  absence  of  these  arteries,  or  of  these  nerves  ? 
A  logical  mind  can  hardly  be  satisfied  with  the  explanations 
they  have  given.  The  truth  is,  that  all  we  hnoio  with  cer- 
tainty is,  that  we  hnow  nothing  certain  on  the  subject ;  and 
it  yet  remains  a  problem  for  future  organologists  to  solve. 

Some  of  the  organologists  endeavor  to  prove  that  all  con- 
genital malformations  or  anomalies  have  their  origin  in 
"  arrested  development,^''  which  theory  is  now  erected  into  a 


44 


INTRODUCTION. 


law  by  Meckel  and  Geoffroy  Saint-Hilaire,  and  most  ingen- 
iously illustrated  by  Serres  in  his  various  wori^s  on  transcen- 
dental anatomy,  and  by  Isodore  Geoffroy  Saint-Hilaire  {tlie 
son)  in  his  work  on  Teratology.  Tliis  theory  has  been  carried 
BO  far  that  some  of  its  enthusiastic  advocates  even  contend 
that  "  a  woTYian  is  only  an  imperfect  or  incomplete  man  /  a 
man  arrested  in  his  develop') nent.^^  This  law,  however,  fails 
to  apply  to  a  number  of  the  congenital  irregularities  of  struc- 
ture, of  not  unfrequent  occurrence,  so  that  M.  Isodore  Saint- 
Hilaire  has  been  compelled  to  add  another  law — that  of 
"  execs  de  developpement^^  in  order  to  account  for  some  of  these 
anomalies  ;  his  father  Geoffroy  Saint-Hilaire,  however,  attrib- 
utes all  such  to  certain  accidents  during  foetal  life ;  whilst 
Meckel  reo-ards  them  as  the  results  of  disease  in  the  ovum. 
But  it  was  not  my  intention,  neither  does  it  fall  within  the 
scope  of  this  work,  to  enter  minutely  into  the  subject  of  the 
cause  of  these  congenital  imperfections;  and  as  I  have 'per- 
haps already  devoted  too  much  time  to  it,  I  must  not  any 
longer  detain  the  reader  by  instituting  any  further  examin- 
ation into  the  theories  of  these  authors  ;  nor  into  that  which 
attributes  all  the  congenital  defects  to  the  principle  "  of  the 
original  germ  heing  imperfect  /  or  of  its  becoming  so  after 
impregnation^  Those  readers  who  wish  to  know  more  on 
this  most  important  and  curious  subject,  and  to  trace  the  her- 
culean labors  of  the  distinguished  organologists,  the  immortal 
Geoffroy  Saint-Hilaire,  who  was  one  of  the  most  profound 
and  indefatigable  men  of  France  in  his  day  :  the  celebrated 
Prof  J.  F.  Meckel  of  Halle  in  Germany,  whose  reputation 
as  an  anatomist  and  as  a  man  of  profound  science  is  unequaled, 
and  M.  Serres  one  of  the  most  accomplished  and  distinguished 
anatomists  of  France,  will  find  it  of  infinite  advantage  to  con- 
sult their  writings. 

There  are  some  of  the  congenital  malformations  of  the  anus 
and  rectum  which  do  not  depend  upon  either  an  arrest  of,  nor 
on  an  excess  of  development,  but  are  the  result  of  disease  in 


INTUODUCTION.  45 

iiitra-utcriiie  life.  A  few  such  cases  have  coiue  under  my 
own  observatit>u.  For  instance  the  anornuil  narrowing  or 
contraction  of  the  anus,  which  is  sometimes  observed  in  new- 
born children,  and  which,  when  attended  with  more  or  less 
thickening  and  induration  of  the  integument,  is  the  result  of 
inflamuuition  of  the  anus  during  foetal  life.  At  other  times 
this  congenite  contraction  is  caused  by  a  preternatural  activity 
of  the  sphinctores  ani  muscles.  In  such  a  case  the  coarctation 
from  being  at  first  purely  spasmodic,  may  gradually  become 
organic  and  permanent. 

Obliteration  of  the  anal  aperture,  or  of  the  rectum  for  a 
greater  or  less  distance  above  the  anus,  may  be  caused  by 
rectitis  during  foetal  life.  In  such  a  case  the  inflammation 
within  the  rectum  causes,  in  process  of  time,  a  coalescence  of 
its  parietes,  and  thus  produces  the  malformation  in  question. 
The  same  may  ultimately  result  froin  permanent  contractions 
of  the  anus  and  the  rectum. 

Peritonitis  may  occur  during  intra-uterine  life,  giving  rise 
to  adhesions  between  the  intestines,  aud  to  effusion  of  lymph 
and  serum  into  the  abdominal  cavity,  and  thus  occasion  mal- 
formations, if  not  the  death  of  the  foetus. 

M.  Desormeaux  records  the  case  of  a  child  whom  at  birth 
displayed  all  the  evidences  of  violent  enteritis,  but  afterwards 
recovered.  He  is  of  opinion  that  the  congenital  contractions 
and  obliterations  of  hollow  canals — such  as  the  oesophagus, 
intestinal  canal,  anus  and  urethra,  &c.  ought  to  be  referred  to 
the  influence  of  previous  inflammation.  {Dlctionnaire  de 
Medicine  de  Paris,  tome  XY.  j).  403.) 

Dnges  relates  the  case  of  a  new^-born  child,  in  whom  the 
abdominal  viscera  were  found  agglutinated  by  a  yellow  col- 
ored and  firm  lymph.  There  were  false  membranes  on  the 
liver,  the  spleen,  the  bladder,  &c.  The  epiploon  was  adher- 
ent to  the  intestines,  which  were  agglutinated  into  a  lump, 
were  yellow,  hard  and  thick.      {ReoherGhes  sur  les  Maladies 


46  iNTRODUCriOKi 

les   plus    importantes  et  les  moins  connites  des  enfans  noit- 
veaux — lies.  Paris.  1821.) 

Otlier  instances,  of  the  eflfects  of  former  inflcanimation  in  the 
intestines  of  new  born  children,  are  related  by  the  following  au- 
thors— M.  Billard.  {Traite  des  Maladies  des  Enfans  nmtveaux 
— iicset  d  la  Mamelle,  p.  441.  Paris.  1828.)  Cams.  {Lehrhuch 
der  Gynah>lag.i^.  Band.  11.  S.  251.  Leipzig.  1820.)  M.  Cruveil- 
hier.  {Anatomie  PatJiologiqae  dii  Carps  Ilamain.  Livraison. 
XV.  PI.  XI.  p>.  2.  ols.  2.  Bruxelles :  1833.) 

It  is  not  easy  to  determine  to  what  cause  these  diseases  of 
intra-uterine  life  should  be  attributed,  at  a  time  when  the 
foetus  in  utero  is  so  completely  protected  from  all  those  influ- 
ences from  without  which  may  induce  inflammation  after 
birth. 

Sex  has  been  supposed  by  some  to  exercise  great  influence 
in  the  production  of  defective  congenital  develojjments.  It  is 
most  certainly  true  that  malformations  are  most  common 
among  males  ;  but  why  it  should  be  so  seems  to  me  not  easy 
of  explanation. 


SECTION    lY. 

ANATOMICAL  AND  PATHOLOGICAL  CHARACTERS. 

The  congenital  malformations  of  the  anus  and  the  rectum 
present  a  great  variety  of  forms,  from  the  most  simple  to  the 
most  complicated,  so  that  it  is  by  no  means  an  easy  task  to 
enumerate  and  to  describe  them,  M.  Guersant  says  that  he 
has  ■  operated  on  more  than  thirty  cases,  and  that  each  and 
every  case  was  dissimilar.  {Gazette  des  Ilopltaux.  No. 
LXX.  p.  280.  Paris  :  1857.) 

I  will  now  consider  the  anatomical  and  the  pathological 
conditions  which  constitute  the  most  common  of  these  vices 
of  structure. 


INTRODUurloN.  47 

1.  The  anus  may  be  more  or  less  prctcmaturally  naiTowed 
at  its  margin  and  sometimes  for  a  short  distance  above.  This 
congcnite  coarctation,  in  such  cases,  is  most  always  organic  or 
structural,  yet  sometimes,  though  not  often,  it  is  purely  spas- 
modic. 

2.  The  marginal  integuments  of  the  anus  may  sometimes 
extend  over  the  border  of  the  sphincter  ani,  thereby  inducing 
both  deformity  and  contraction. 

3.  The  anus  and  the  rectum  may  be  normal,  but  the  simple 
thin  and  delicate  membranous  septum  of  foetal  life  may  still 
exist,  and  thus  produce  a  complete  occlusion  of  the  anal  ori- 
fice. The  anal  aperture  too,  is  sometimes  completely  closed 
by  a  very  thick  and  hard  membrane,  or  a  substance  analagous 
to  it. 

4.  The  anus  may  be  entirely  absent,  no  sign  whatever  indi- 
cating where  it  should  be  ;  the  scrotal  raphe  being  continued 
without  interruption  back  to  the  coccyx.  In  such  a  case  the 
rectum  may  also  be  partially  or  entirely  absent,  and  the 
sphinctores  ani,  may  or  may  not  be  present. 

5.  In  the  absence  of  the  natural  anus  there  may  be  a  pre- 
ternatural one,  performing  the  functions  of  an  anus,  and 
occupying  some  extraordinary  situation.  In  these  instances 
the  rectum  may  be  partially  or  totally  absent,  and  the  colon 
also  may  be  wanting. 

6.  The  rectum  at  some  point  in  the  pelvis  more  or  less 
distant  above  its  natural  outlet,  may  terminate  in  a  cul-de-sac, 
and  either  hang  loosely  or  be  attached  to  some  of  the  sur- 
rounding parts,  there  being  no  indication  wdiatever  of  an 
anus. 

7.  Tlie  rectum  may  be  interrupted  at  a  variable  distance 
above  a  naturally  formed  anus,  by  a  thin  or  thick  annular 
membranous  septum  like  a  diaphragm.  Sometimes  it  is  com- 
pletely closed  at  several  points  by  such  membranous  septa,  its 
diameter,  however,  at  those  points  remaining  undiminished, 


48  INTRODUCTIO?r. 

and  the  canal,  with  the  exception  of  these  j)artitions  being 
entirely  natural. 

8.  The  anus  being  normal,  the  rectum  for  a  greater  or  less 
distance  above  it,  may  degenerate  into  a  solid  mass  resem- 
bling a  cord,  or  be  entirely  wanting  ;  or  this  degeneration  may 
be  confined  only  to  its  superior  portion,  and  reassume  its 
cylindi'ical  shape  again  as  it  approaches  the  anus,  forming,  as 
it  were  a  pouch  at  its  inferior  extremity. 

9.  The  rectum  may  be  completely  obliterated  throughout 
its  whole  extent,  by  a  thickening  of  its  coats,  its  walls  approx- 
imating and  firmly  adhering  as  though  glued  together;  or 
this  obliteration  may  take  place  at  one  or  two  points  only  in 
the  course  of  the  rectum,  the  canal  at  these  places  appearing 
as  if  tied  with  a  tape  ;  the  anus  and  intervening  spaces  being 
natural. 

10.  The  rectum  may  be  present  and  present  its  cylindrical 
form,  whilst  its  cavity  may  be  completely  blocked  up  with  a 
substance  of  a  cellulo-fibrous  character;  no  anus  being 
present. 

11.  Tlie  rectum  may  terminate  in  the  bladder  or  the  ure- 
thra ;  or  in  the  vagina,  or  the  uterus ;  or  in  a  cloaca  in  the 
perinsEum,  with  the  urethra  and  the  vagina.  In  these  in- 
stances there  is  generally  no  sign  of  a  normal  anus  ;  yet  some- 
times, though  rarely,  it  does  exist,  and  permits  the  introduc- 
tion of  the  end  of  the  probe  for  a  few  lines. 

12.  Tlie  rectum  may  terminate  in  the  sacral  region  by  an 
abnormal  anus  ;  it  may  be  prolonged  in  the  form  of  a  fistulous 
sinus,  and  terminate  by  an  abnormal  opening  at  difterent 
points  in  the  perinaeum  ;  at  the  glans  penis,  labia  pudendi, 
&c.     In  these  cases  the  normal  anus  is  generally  absent. 

13.  The  rectum  may  be  entirely  wanting  and  its  place  sup- 
plied by  a  fatty  cellular  tissue.  In  these  instances  the  colon 
ends  in  a  cul-de-sac,  with  or  without  a  ligamentous  appendage 
in  continuation,  and  is  either  ^dherent,or  floats  loosely  in  the 


INTKODUCTION.  49 

pelvic,  or  abdoniiiuiml  cavity.     No  iionnul   {iims  exists,  but 
sometimes  an  abnormal  one  does. 

14.  The  rectmn  and  the  colon  may  botli  ])o  absent.  In 
these  instances  there  is  no  natural  anus,  but  often  a  preterna- 
tural one  situated  in  some  unusual  or  extraordinary  region  of 
the  body,  communicating  either  with  the  cajcuni  or  some 
portion  of  the  small  intestines. 

15.  With  any  of  these  malformations  there  may  coexist  iu 
the  same  patient  a  further  deformity  of  some  of  the  neighbor- 
ing sexual  organs  in  a  greater  or  less  degree ;  or  of  some 
arrest  of  development — as  fissure  of  the  scrotum,  witli  the 
glans  penis  and  the  meatus  in  the  perinaeum,  spina  bifida, 
the  absence  of  a  portion  of  an  extremity,  &c.,  &c. 

I  here  consider  it  important,  for  the  better  understanding 
of  the  subject,  to  give  a  short  retrospective  view  of  the  history 
of  the  development  of  the  rectum  and  the  anus. 

These  two  organs,  the  rectum  and  the  anus,  in  their  evolu- 
tion, like  other  portions  of  the  organization,  pass  through 
several  types  and  degrees  of  development  before  they 
attain  that  perfect  form  and  arrxingement  destined  to 
represent  their  permanent  condition.  The  formative  process 
may  be  impeded  at  any  one  of  these  stages  of  development, 
and  cause  such  derangement  of  their  evolution,  as  would  more 
or  less  interfere  with  their  normal  growth,  and  exhibit  at 
birth  the  precise  character  which  was  impressed  upon  them 
when  the  liinderance  first  occurred. 

In  the  early  period  of  fcetal  life  the  rectum  and  the  amis 
are  isolated,  the  former  is  lodged  in  the  abdominal  cavity,  but 
it  gradually  descends  into  the  pelvis  to  meet  the  latter  ;  tliey 
both  continue  to  progress,  and  to  approach  each  other,  attain- 
ing their  proper  dimensions  by  successive  accretions,  the  first 
from  the  mucous  and  the  second  from  the  serous  layer,  and  in 
due  time  their  extremities  meet  and  coalesce,  and  the  common 
conduit  is  thus  formed.  Should  arrest  of  development  occur 
at  any  period  during  this  natural  process,  in  one  or  the  other  of 


50  IXTKODUCTION. 

these  organs,  or  in  both  of  them  at  the  same  time,  various 
malformations  peculiar  to  each  might  be  produced. 

The  rectum  during  embryonic  life  is  confounded  with  the 
bladder,  the  urinary  and  genital  canals  terminating  in  one 
common  cloaca — Whence  a  derangement  of  the  formative  pro- 
cess, at  this  period,  in  either  the  rectum,  or  in  any  one  of  the 
genito-urinary  organs,  might  cause  one  or  all  of  them  to  be 
more  or  less  defective — resulting  in  either  a  limited  or  an  ex- 
tensive imperforation  of  the  rectum,  or  in  some  anormal  com- 
munication between  it  and  the  bladder,  the  urethra  or  the 


'? 


vagina. 


At  an  early  period  of  foetal  life  the  anus,  together  with  the 
other  external  openings  of  the  body,  is  covered  with  a  peculiar 
skin,  somewhat  analogous  to  that  which  covers  the  surface  of 
the  body.  Tliis  skin,  should  the  evolution  of  the  fostus  go  on 
naturally,  becomes  gradually  thinner,  appearing  ultimately 
as  a  peculiar  secreting  membrane,  and  is  finally  removed  from 
its  situation  over  the  anal  orifice  by  absorption.  Should  this 
normal  process  of  absorption  be  arrested,  or  cease  to  go  on, 
however,  this  skin  or  membrane  would  remain  stationary  over 
the  anal  aperture  and  consequently  form  an  atresia  ani.  It 
will  thus  be  seen  that  in  such  instances  of  imperforation  of  the 
anus,  that  the  occluding  skin  or  membrane  was,  in  the  early 
stage  of  foetal  existence,  a  normal  formation. 


rSTUODUCTION. 


51 


SYNOPSIS. 


The  Congenital 
Malformations  ^ 
of  the  Anus. 


1.  Preternatural  narrowing. 

2.  Occlusion  by  a  tliin  int'inl)rane. 

3.  Occliision  by  a  thick  hard  nicmbraiic. 

4.  Partial  or  complete  absence. 

5.  Abnormal. 


Occlusioyi  of 
the    Meet  am. 


Obliteration  of 
the  Mectuniu 


The  Congenital 
Malformations  \ 
of  the,  Rectum. 


Preternatwral 

termination 
of  the  Rectum. 


Pretematiival 

termination  of 

other  organs  %n 

the  Rectum, 


"1.  By  one   membranous 

septum. 
2.  By  two  or  more  mem- 
branous septa. 

'1.  By  the  agglutination 
of  its  parietes, 

2.  By   the  j)uekering  of 

its  parietes. 

3.  By  the  thickening  and 

the  induration  of  its 
parietes. 

1.  In  a  cul-de-sac. 

2.  In  the  bladder. 

3.  In  the  urethra. 

4.  In  the  vagina. 

5*  In  a  cloaca  in  the  peri- 
naeum  with  the  vasri- 
na  and  urethra. 

6.  In    the    ano-perinteal 

region,  at   difierent 
points. 

7.  In  the  sacral  region. 

1.  Of  the  ureters. 

2.  Of  the  vagina. 

3.  Of  the  uterus. 


Absence  of  the  (  1.  Partial. 


Rectum, 


{I: 


Complete. 


52  INTRODUCTION. 

SECTION    V. 

CLASSIFICATION. 

Taxing  as  a  basis  of  classification,  the  anatomical  and  tlie 
pathological  condition  of  the  various  congenital  malforma- 
tions and  imperfections  of  the  anus  and  the  rectum,  I  will  dis- 
tinguish them  all  into  nine  species,  each  one  of  which  may 
comprise  a  greater  or  a  less  number  of  varieties.  In  this  ar- 
rangement I  have  considered  convenience  and  usefulness  ra- 
ther than  an  appearance  of  scientific  precision,  I  am  well 
aware  that  it  is  not  perfect,  but  I  trust  it  will  be  found  sufii- 
ciently  plain,  comprehensive  and  correct  for  all  practical  jjur- 
poses.  Tliis  division  corresponds  somewhat  to  that  suggested 
by  Papendorf  many  years  ago,  whose  divisions  and  definitions 
of  the  congenital  malformations  of  the  anus  and  the  rectimi^, 
although  quite  imperfect,  yet,  are,  for  the  purposes  designed, 
as  good  as  any  I  have  observed  of  a  later  date.  {Dissertatio 
sistens  observationes  \de  ano  infantum  imperforato.  Lugd, 
Batav.  1781.  Uo.) 

FIEST  SPECIES. 

This  species  consists  of  a  preternatural  narrowing  of  the 
anus  at  its  margin,  and  occasionally  extending  a  short  distance 
above  this  point. 

SECOND    SPECIES. 

In  this  species  there  is  a  complete  occlusion  of  the  anal 
aperture  by  a  simple  membrane ;  or  by  the  common  integu- 
ment, or  a  substance  analogous  to  it,  more  or  less  thick  and 
hard. 

TIIIKD   SPECIES. 

In  this  species  there  is  no  anus  whatever,  the  rectum  being 
partially  deficient  and  terminating  in  a  cul-de-sac  at  a  greater 
or  less  distance  above  its  natural  outlet,  without  any  commu- 
nication whatever,  either  externally  or  internally. 


TNTRODUCTIOJr.  53 

FOURTH  SPECIES. 

The  anus  in  tliis  species  is  normal,  but  the  rectum  at  vari- 
able distances  above  it,  is  either  deficient,  obliterated,  or  com- 
pletely obstructed  by  a  membranous  septum. 

FIFTH  SFECIES. 

In  this  species  the  rectum  terminates  externally  by  an  ab- 
normal anus,  located  in  some  unnatural  situation,  as  at  some 
point  in  the  sacral  region  ;  or  the  rectum  is  prolonged  in  the 
form  of  a  fistulous  sinus  and  terminates  by  an  abnormal  anus, 
at  the  glans  penis,  the  labia  pudendi,  or  at  different  points  in 
the  perinagum.  The  natural  anus  being  generally  absent,  its 
functions  are  performed  by  the  abnormal  one. 

SIXTH   SPECIES. 

Tlie  rectum  in  this  species  opens  preternaturally  into  the 
bladder,  the  urethra,  or  the  vagina ;  or  into  a  cloaca  in  the 
perinseum  with  the  urethra  and  the  vagina.  In  these 
instances  the  normal  anus  does  not  generally  exist. 

SEVENTH  SPECIES. 

In  this  species  the  rectum  is  normal,  with  the  exception 
that  either  the  ureters,  the  vagina  or  the  uterus,  open  preter- 
iiiiturally  into  it 

EIGHTH  SPECIES. 

In  this  species  the  rectum  is  entirely  wanting. 

NINTH  SPECIES. 

In  tbis  species  the  rectum  and  the  colon  are  both  absent, 
,and  there  is  usually  an  abnormal  anus  situated  in  some  extra 
.ordinary  part  of  the  body. 


'.54:  INTKODUCTION. 

SECTION     VI, 

GENERAL  SYMPTOMS. 

Should  any  of  these  congenital  vices  of  structure  have  jm- 
fortunately  escaped  the  observation  of  the  accoucheur  or  the 
nurse  at  the  time  of  the  hirth  of  the  child,  its  existence  in  the 
majority  of  instances  would  sooner  or  later  manifest  itself  by 
a  train  of  morbid  phenomena  simulating,  strangulated  hernia,, 
the  result  of  the  retention  of  the  meconium  and  other  matter. 
K  no  alvine  dejections  take  place  within  twelve  or  twenty- 
four  hours  after  birth,  the  child  gradually  becomes  restless,, 
and  by  its  peculiar  plaintive  cries  manifests  the  suifering  it 
now  begins  to  endure.  These  cries  are  generally  attributed 
by  the  nurse,  to  colic,  and  the  little  suiferer  is  treated  accord- 
ingly with  all  kinds  of  medicines,  but  generally  to  none  but 
the  worst  of  purpose.  The  abdomen,  especially  in  the  hypo- 
gastric region,  now  becomes  enlarged,  tense,  hot,  shining,  and 
painful  upon  pressure,  the  respiration  becomes  difficult  and 
irregular,  and  the  pulse  frequent,  small  and  contracted.  To 
these  symptoms,  if  no  amendment  soon  takes  place,  vomiting 
will  be  added,  first,  of  all  the  milk  and  other  fluids  swallowed, 
then  of  the  mucous  and  biliary  secretions,  and  finally,  of  the 
meconium,  or  a  dark  brownish  matter  analogous  to  it» 
Should  no  relief  still  be  afforded  the  little  sufferer,  these 
symptoms  will  become  augmsented  in  violence ;  the  diaphragm 
and  other  abdominal  muscles  will  become  excited  to  violent 
expulsive  efforts,  during  which  respiration  will  sometimes 
become  suspended,  the  face  will  become  swelled,  discolored 
and  covered  with  perspiration  ;  the  voice  sooner  or  later  will 
become  almost  extinct ;  there  will  be  hiccup,  with  coldness- 
and  flexure  of  the  extremities  and  convulsions.  In  the  male,, 
inflation  of  the  scrotum  and  penis  sooner  or  later  takes  place. 
Should  matters  thus  continue,  death  is  inevitable  and  is  soon 
ushered  in ;  and  it  usually  takes  place  between  the  third  and 
the  eighth  day,  according,  to  the  vigor  of  tlie  little  patient. 


INTliODUCTION.  55 

Before  death  occurs  there  is  often  a  ^^encral  yellowness  oi'  tlie 
skin.  When  the  case  is  protracted  for  a  number  of  days  the 
emaciation  becomes  extreme,  and  the  patient  dies  from  the 
etfects  of  inanition. 

Strange  to  say,  that  cases  of  complete  occlusion  of  the  rec- 
tum have  occurred,  in  which  life  had  been  prolonged  for  a 
number  of  days,  and  even  for  months  witliout  any  evacuation 
from  the  bowels,  and  before  any  violent  symptoms  had  taken 
place. 

Wolf  mentions  a  case  of  imperforation  of  the  anus  and  rec- 
tum in  which,  strange  to  say,  the  deformity  was  not  discover- 
ed and  no  unfavorable  symptoms  manifested  themselves  until 
the  evening  of  the  twelfth  day,  the  child  during  this  time  not 
having  had  any  motion  from  its  bowels,  when  it  was  attacked 
with  vomiting,  hiccup  and  convulsions,  attended  with  disten- 
tion and  hardness  of  the  abdomen  and  great  prostration. 
[Yide  Case  LIX.] 

A  still  more  remarkable  case  of  imperforate  rectum  is  re- 
ported by  Dr.  A.  B.  Shipman  of  Courtlandville,  in  the  State 
of  New- York.  In  this  instance  the  child  lived  three  months 
without  passing  anything  from  its  bowels.  He  says  the  child 
was  nearly  as  large  as  ordinary  children  of  that  age,  and  was 
not  afflicted  with  vomiting  or  crjang  more  than  many  are, 
who  are  considered  healthy.     [Yide  Case  XXIX.] 

Mr.  West  says  that  Mr.  Arnott  communicated  to  him  a  case 
in  which  the  child  lived  seven  weeks  and  three  days,  the  rec- 
tum being  entirely  absent,  and  the  colon  terminating  in  a 
blind  sac,  and  floating  loosely  in  the  abdominal  cavity.  {Ojj. 
cit.p.  376.) 

De  La  Marre  mentions  an  instance  of  a  child  having  an  anal 
imperforation,  which  lived  six  months  without  ever  having 
had  any  evacuation  from  its  bowels.  In  this  case  the  milk 
and  everything  else  taken  into  the  stomach  were  constantly 
ejected  by  vomiting.  {.Journal  de  Medlcme  de  Paris,  annee. 
1770.  tome  XXXIIL  ^.  510.) 


56  INTBODirCTION. 

A  case  is  reported  iii  tlie  "  Provincial  Medieal  and  Surgi- 
cal Journal "  for  March,  1851,  in  which  a  child  having  an  im- 
perforate anns  lived  one  hundred  and  two  days  without  hav- 
ing any  evacuation  from  its  bowels,  and  dm-ing  this  time 
never  vomited. 

Death  in  instances  of  imperforation  of  the  anus  or  the  rec- 
tum, is  usually  the  result  of  enteritis,  peritonitis  and  intestinal 
paralysis. 

Sometimes  previous  to  death  in  consequence  of  the  violent 
expulsive  efforts  to  overcome  the  obstruction,  the  colon,  or 
some  other  portion  of  the  intestinal  canal  bursts,  and  its  con- 
tents are  poured  into  the  peritonseal  cavity,  death  being 
ushered  in  by  the  sudden  supervention  of  a  state  of  collapse. 
A.  case  of  this  kind  is  related  by  M.  Fourcade.  {RevueMedi- 
cale  de  Paris,  annee.  1830.  tome  VI.  y.  52.) 

On  dissection,  the  intestines  will  be  found  enormously  dis- 
tended with  gas,  meconium  and  other  matters,  and  highly 
inilamed. 

The  distention  or  tympinitic  state  of  the  abdomen  in  these 
cases  is  caused,  in  part,  by  the  disorganization  which,  at  an 
early  period  takes  place  in  the  contents  of  the  intestines,  by 
which  great  quantities  of  gas  are  disengaged.  The  intestinal 
nerves  become  affected,  hence  the  spasms.  The  blood  vessels 
of  the  lower  extremities  too,  become  compressed,  and  this 
comj^ression  induces  congestion  of  the  heart,  lungs,  and  brain. 
This  phenomenon  is  very  evident  when  the  distended  cavity 
of  the  abdomen  presses  upon  the  thoracic  viscera.  The  com- 
pressed lungs  no  longer  admit  full  respiration ;  the  vital 
transformations  of  the  blood  are  inadequately  made,  and  at  the 
same  time,  as  the  excrementitious  matters  of  the  body  cannot 
be  carried  off  by  defecation,  the  composition  of  the  blood 
becomes  such  as  no  longer  to  afford  any  nourishment  to  the 
vital  organs. 

Conjointly  with  the  general  signs  of  intestinal  obstruction, 
there  are  in  each  case  some  special  indications  of  the  peculiar 


INTRODDCrriON.  57 

form  of  niixlforination  to  which  the  obstruction  is  due.  These 
special  symptoms  will  be  fully  given  in  the  following  clia})ters, 
on  the  different  species  of  malformation. 

The  pathognomonic  sign  is  obtained  by  the  direct  inspection 
of  the  anus  and  the  rectum. 


SECTIOi^"    VII. 
PROGNOSIS. 

Anciently  the  malformations  of  the  anus  and  the  rectum, 
together  with  those  of  the  genito-urinary  organs,  were  looked 
upon  as  necessarily  fatal,  and  the  unfortunate  victims  of  them 
were  regarded  in  the  light  of  monsters,  and  left  to  perish. 
Even  at  tlie  present  day  this  sentiment  prevails  to  a  certain 
extent,  and  the  subject  is  still  surrounded  by  no  inconsider- 
able degree  of  mystery,  the  most  insignificant  deviations  from 
the  natural  standard  being  apt  to  be  exaggerated  and  invested 
with  an  importance  which  by  no  means  legitimately  belongs 
to  them. 

When  we  take  into  consideration  the  fragility  of  the  sub- 
jects, the  deplorable  nature  of  some  of  the  species  of  these 
malformations,  and  the  formidable  character  of  some  of  the 
operations 'necessary  for  their  relief,  the  hope  of  ultimate  suc- 
cess does  indeed  appear  but  slight ;  yet  such  are  the  great 
improvements  that  have  been,  and  are  being  made  in  modern 
surgery,  that  the  evil  is  by  no  means  deplorable,  even  in  some 
of  the  w^orst  cases,  as  will  be  shown  hereafter.  'No  case 
should  be  abandoned  in  despair,  although  surrounded  by  the 
most  discouraging  circumstances.  Many  of  the  cases  may 
be  relieved  immediately  by  simple  and  appropriate  trea-tment, 
and  others  admit  of  certain  relief,  by  prompt  surgical  meas- 
ures, which  not  only  save,  but  prolong  life,     Tlie  surgeon 


58  INTRODUCTION. 

must  be  very  careful,  however,  not  to  promise  the  parents  or 
the  friends  of  the  child  too  much  even  in  the  most  simple 
case,  recollecting  how  natural  it  is  for  them  to  imagine  that 
if  the  operation  succeeds,  all  will  be  well,  and  that  the  child 
will  be  left  in  every  respect  perfect.  This  would  be  a  great 
mistake,  as  every  surgeon  knows  who  has  had  any  experience 
in  endeavoring  to  remedy  defective  formations.  Therefore,  to 
prevent  misconception  on  this  point,  and  the  evil  conse- 
quences of  it,  the  surgeon  must  previously  explain  to  them 
that  the  operaition  may  indeed  afford  an  outlet  and  immediate 
relief ;  but  that  such  an  artificial  opening  or  anus,  not  being 
formed  by  nature  for  the  specific  purpose,  cannot  be  expected 
to  possess  all  the  powers  or  to  perform  all  the  functions  of 
which  the  natural  anus  would  have  been  capable. 

The  most  favorable  cases  of  course  are  those  which  require 
the  least  surgical  assistance — such  in  which  there  is  a  con- 
traction of  the  anal  orifice,  and  requires  but  simple  dilatation, 
or  such  in  which  the  anal  orifice  is  obstructed  by  a  membrane 
which  only  requires  to  be  divided. 

Tlie  most  formidable  cases  are  those  in  which  there  is  a 
considerable  deficiency,  or  an  entire  absence  of  the  rectum, 
and  in  which  there  exists  no  outlet  whatever.  In  all  such 
cases,  without  an  operation,  death  soon  takes  place  from 
necessity.  Some  surgeons,  however,  consider  all  such  cases 
necessarily  fatal,  and  beyond  the  power  of  art  to  remedy : 
yet,  as  I  will  hereafter  show,  even  a  number  of  such  cases  have 
been  relieved,  by  either  the  operation  of  proctoplasty  or  colot- 
omy.  In  such  a  case  even  a  doubtful  remedy  should  be 
2)referred  and  attempted  in  preference  to  the  certain  death  of 
the  infant, 

Tliose  cases  in  which  the  rectum  opens  into  the  bladder  by 
an  abnormal  anus,  or  into  the  urethra,  or  the  vagina ;  or  in 
which  there  exists  a  preternatural  anus  on  some  part  of  the 
body,  are  not  so  formidable  and  do  not  terminate  in  death  so 
quickly.     Some  of  them  may  be  entirely  relieved,  others 


INTRODUCTION.  39 

greatly  benefitted,   whilst  otliera  again  admit  of  palliative 
treatment  only. 

Some  very  remarkable  cases  are  recorded  of  life  having 
been  sustained  and  prolonged  for  days,  months,  and  even 
vears,  in  which  no  anus  whatever  existed,  nor  in  which  had 
any  operation  been  performed.  In  these  instances  there  was 
consid(^-able  deformity  too  of  the  genito-urinary  organs, 

A  man  forty  years  of  age  was  seen  by  Bartholin,  in  whom 
no  anus  existed,  but  who  discharged  his  fseces  from  his  mouth 
by  means  of  a  horn,  made  for  the  purpose,  and  who  voided 
his  urine  from  the  umbilicus.  {Historia  Anatomicce,  cent.  I. 
ohserv.  LXV.  f,  113.) 

Baux  saw  a  girl  fourteen  years  old  who  had  neither  an  anal, 
a  genital,  nor  a  urinary  opening.  There  was  not  the  least 
appearance  of  these  apertures,  the  skin  being  smoothly  contin- 
ned  over  the  situation  naturally  occupied  by  them,  as  on  other 
parts  of  the  body.  At  the  end  of  every  third  day  she  experi- 
enced considerable  pain  around  the  umbilicus,  and  immediately 
after  would  eject  faecal  matter  by  vomiting.  Her  urine  was 
entirely  voided  by  the  nipples  every  three  or  four  hours. 
This  girl  was  well  formed  in  other  respects,  and  of  a  veiy 
agreeable  person.  She  had  a  good  appetite,  slept  well,  and 
had  general  good  health.  {Journal  de  Medicine  de  Paris 
tome  YIII.  J).  59.) 

These,  however,  are  extraordinary  cases,  they  form  the 
exception  to  the  rule,  and  they  must  not  lead  the  practitioner 
to  the  conclusion  that  in  cases  similar  no  operation  for  their 
relief  should  be  undertaken.  !No  one  will  dispute  the  neces- 
sity of  an  operation  in  a  case  of  atresia  ani,  because  single 
cases  have  been  known  to  exist  in  which  children  have  lived 
for  days,  months,  and  even  years  without  such  surgical  inter- 
ference. Tlie  observation  made  by  the  celebrated  Callisen 
many  years  ago,  still  stands  firm,  and  must  not  be  forgotten. 
"  The.  atresia  ani,"  says  he,  "  will  certainly  be  followed  by 
death,  unless  a  passage  is  formed  and  maintained."  (Sy sterna 
Chii'urgie^  Hod.  tome  II.  p.  840.  Hqfnice.  1800.) 


60  mTRODUCTION. 

The  operation  for  the  establishment  of  an  artificial  anus, 
either  in  the  perinaeum,  or  in  the  abdomen,  seems  so  grave  a 
one  for  a  child  at  so  tender  an  age,  that  many  surgeons 
decline  it  altogether.  This  consideration  alone,  however, 
should  by  no  means  deter  the  surgeon  from  operating,  for  it 
is  an  established  fact,  and  the  knowledge  of  it  should  be  more 
universally  known — that  children  sustain  an  operation  much 
better  soon  after  birth,  than  at  a  later  period.  This  is  doubt- 
less in  consequence  of  the  small  vital  development  of  new- 
bom  children,  who,  in  this  respect,  are  similar  to  the  inferior 
animals.  This  analogy  rests  upon  the  recuperative  power 
common  to  them  both,  by  virtue  of  which  wounds  in  both 
are  followed  by  very  slight  inflammation,  or  even  none  at  all, 
and  show  a  direct  tendency  to  heal  by  the  first  intention. 


CH^I^TER   II. 

THE  FIRST  SPECIES  OF  MALFOEMATION. 

SECTION    I. 

DESOKIPTION. 

1.  This  specieis  of  congenital  malformation  is  characterized, 
as  has  been  already  observed,  by  an  abnormal  narrowing  of 
the  anal  orifice,  which  contraction,  however,  is  by  no  means 
always  confined  to  the  verge  of  the  anus,  but  is  occasionally 
found  extending  up  into  the  canal  itself,  and  consisting  some- 
times of  numerous  folds  projecting  into  the  cavity  of  the 
rectum,  and  which,  according  to  their  degree  of  development, 
more  or  less  obstruct  the  physiological  functions  of  it.  Some- 
times the  marginal  integument  of  the  anus  extends  over  the 
border  of  the  sphincter  muscle  and  thus  produces  both  con- 
traction and  deformity. 

2.  This  congenital  narrowing  is  usually  organic,  being 
attended  with  more  or  less  thickening  and  induration  of  the 
integument  about  the  anus,  the  result  doubtless  of  previous 
inflammation;  at  other  times  however,  the  contraction  is 
purely  spasmodic,  depending  upon  a  peculiar  condition  of 
the  sphinctores  ani  muscles  which  are  found  to  be  preternatu- 

rally  active. 

3.  The  anal  opening  and  the  cavity  of  the  rectum,  in  these 
instances  of  congenital  contraction,  may  present  all  the  diflerent 
deo-rees  of  stricture,  from  that  into  which  the  point  of  the 
smallest  probe  cannot  be  introduced,  and  impossible  for  the 
meconium  to  pass,  to  that  which  opposes  no  obstruction  w^hat- 


62  THE  FIRST   SPECIES   OF   MALFOEMATION. 

ever  to  the  common  sized  probe,  and  but  little  to  the  passage 
of  the  meconium  or  the  excrementitious  matters. 

4.  Tlie  situation  and  the  form  of  the  anus  in  this  species  of 
malformation  are  generally  normal,  but  the  preternaturally 
contracted  or  puckered-up  orifice,  always  presents  the  pli- 
cated appearance  of  the  mouth  of  a  purse  tightly  drawn. 

5.  The  signs  of  the  congenital  coarctation  of  the  anus,  or 
the  rectum,  are  the  absence  or  the  deficiency  of  the  meco- 
nium in  the  napkin  which  the  child  wears,  the  progressive 
and  painful  tension  of  the  abdomen,  and  vomiting.  The 
pathognomonic  sign  is  furnished  by  the  direct  inspection  of 
the  anus. 

6.  There  is  one  variety  as  it  may  be  termed,  of  this  species 
of  malformation  which  must  not  be  omitted  here  ;  it  is  the 
anal  contraction  sometimes  observed  in  new-born  children 
who  have  a  syphilitic  taint  which  is  the  cause  of  it.  It  is  of 
the  utmost  importance  that  the  surgeon  or  the  practitioner  of 
midwifery  should  make  the  distinction  between  it  and  the 
other  varieties,  as  it  requires  an  entirely  difi'erent  treatment. 

His  attention  will  be  first  called  to  it  by  some  of  the  same 
signs  which  characterize  the  other  varieties  of  this  species — 
such  as  pain,  severe  straining  efforts  and  difficulty,  at  each 
evacuation,  and  a  peculiarly  small  aperture.  On  a  proper 
examination,  however,  there  will  be  discovered  other  signs 
or  appearances  which  will  explain  the  true  nature  of  the  case 
— such  as  discolorations  of  the  surrounding  integument ; 
excoriations,  and  even  superficial  ulceration  in  the  adjacent 
structures,  with  a  considerable  exudation ;  small  fissures  of 
the  anus,  as  well  as  about  the  commissures  of  the  lips  ;  soft 
granulations,  or  condylomata  are  also  sometimes  present  at 
the  verge  of  the  anus,  discharging  a  tenacious  matter. 
Other  constitutional  symptoms  are  also  usually  present — such 
as  copper-colored  blotches  on  the  skin  ;  a  tendency  to  crack- 
ing and  excoriation  of  the  skin  about  the  hands,  feet  and 


TlIK    FIRST   SPECIES    OF   MALFORMATION.  G3 

nates  ;  an  imperfect  development  of,  or  a  tendency  to  a  sep- 
eration  of  tlie  nails  ;  general  emaciation  ;  suspicious  appear- 
ances about  the  mouth  and  tongue,  and  a  very  remarkable 
and  peculiar  hoarseness  in  crying.  Many,  if  not  most  of 
these  symptoms,  aided  by  the  history  of  the  parents  will  lead 
the  surgeon  to  distinguish  this  peculiar  congenital  contrac- 
tion of  the  anus,  and  enable  him  to  make  his  diagnosis 
accordingly. 

7.  There  are  but  few  cases  of  this  species  of  malformation 
on  record — hence  many  imagine  that  it  is  quite  rare.  I  am, 
however,  of  opinion  that  it  is  much  more  common  than  is 
generally  supposed,  and  the  reason  that  so  few  cases  are 
reported,  is  that  they  are  usually  so  simple  in  their  nature 
and  so  easily  remedied  that  no  further  notice  is  taken  of  them 
by  the  surgeon.  The  slight  ones  too,  are  doubtless  often 
entirely  overlooked.  Two  cases  only  of  this  species  have 
come  under  my  own  observation. 

8.  Immediate  attention  should  be  given  to  children  who 
have  a  congenital  stricture  of  the  anus  or  the  rectum. 


SECTION    II. 

TREATMENT. 

1.  The  treatment  of  this  species  is  generally  simple,  easy  of 
accomplishment  and  most  always  attended  with  success.  It 
is  either  by  dilatation  alone,  or  by  incision  and  dilatation 
combined,  according  to  the  nature  and  straitness  of  the  con- 
traction. In  all  cases  in  which  the  common  probe  can  be 
passed,  simple  dilatation,  if  persevered  in  for  a  short  time, 
scarcely  ever  fails  to  effect  a  cure,  especially  if  commenced 
in  time.     It  is  not  only  applicable  to  the  organic  contraction, 


64  THE   FIRST   SPECIES   OF   MALFOKMATION. 

but  equally  so  to  that  caused  by  a  preternatural  activity  of 
the  sphinctores  ani  muscles. 

2.  The  dilatation  should  be  effected  by  means  of  wa'x, 
gum-elastic  or  metallic  bougies,  similar  in  construction  to 
those  used  for  the  urethra,  but  about  two-thirds  shorter.  I 
prefer  the  wax  bougie  for  this  purpose,  to  all  other  kinds. 
The  bougies  should  consist  of  a  regular  series  of  gradually 
increased  sizes.  The  first  one  should  be  of  such  a  size  as  to 
pass  the  constriction  easily,  care  being  taken  not  to  make  too 
rapid  or  too  great  distension,  but  to  use  the  same  instrument 
for  a  day  or  two  in  succession  before  exchanging  it  for  a  larger 
one.  The  bougie  should  be  used  once  at  least  in  twenty-four 
hours,  by  simply  passing  it  through  the  contraction,  and  then 
immediately  withdrawing  it.  Prolonged  dilatation — that  is, 
the  retention  of  the  bougie  for  a  length  of  time,  I  repudiate 
in  such  cases.  An  enema  of  warm  flax-seed  tea  with  a  little 
pure  olive  oil  in  it,  should  be  administered  about  an  hour  pre- 
vious to  using  the  bougie,  in  order  to  empty  the  rectum,  and 
prevent  the  dangerous  accumulations  which  are  liable  to  take 
place,  as  well  as  to  facilitate  the  introduction  of  the  instru 
ment.  The  bougie  should  always  be  warmed  and  well 
lubricated  with  simple  cerate  previous  to  its  insertion. 

3.  This  course  should  be  persevered  in  until  the  orifice 
has  acquired  it  normal  size,  or  until  the  full  amplitude  of  the 
canal  is  restored.  It  is  important,  however,  even  after  the 
dilatation  has  been  carried  to  the  full  extent,  to  use  the 
bougie  occasionally  in  consequence  of  the  disposition  of  the 
orifice  sometimes  to  contract  again.  It  should  therefore  be 
closely  watched  for  some  time  afterwards. 

4.  Should  any  undue  irritation  or  inflammation  be  excited 
in  the  parts  during  the  process  of  dilatation  some  soothing 
means  should  be  used  to  allay  it — such  as  warm  mucilaginous 
and  opiate  enemata,  frequently  repeated,  or  the  repeated 
employment  of  the  warm  hip  bath  which  is  one  of  the  very 
best  means  for  this  purpose ;   indeed  the  frequent  employ- 


THE   FIllST   SPECIES   OF   MALFOKMATION.  65 

meiit,  during  the  use  of  the  bougie,  of  warm  injections  of  the 
decoctions  oi  althea  or  Jlax-seed^  conjoined  with  the  warm  hip- 
bath, would  greatly  tend  to,  if  not  entirely,  prevent  irritation 
or  inflammation. 

5.  In  the  treatment  of  some  of  these  cases,  the  little  linger 
of  the  child's  mother  or  nurse  if  eitlier  of  them  is  intelligent, 
might  be  substituted  for  the  bougie,  after  the  orifice  has 
been  sufficiently  dilated  by  that  instrument  to  admit  the 
finger.  The  finger  would  greatly  aid  the  bougie  in  over- 
coming the  stricture  and  preventing  its  return,  being  one  of 
the  best  instruments  for  that  purpose,  as  it  can  be  so  easily 
insinuated  into  the  orifice,  and  in  such  a  manner  too,  as  to 
cause  but  little,  if  any  pain,  and  no  injury. 

6.  The  congenite  contraction  in  some  instances  is  so  slight 
that  it  is  apt  to  be  overlooked  or  neglected  during  the 
whole  period  of  infancy,  and  in  other  instances  the  treatment 
is  abandoned  too  soon,  or  before  the  dilatation  has  been 
carried  far  enough  ;  all  owing  doubtless  to  the  fact  that  in 
infancy  the  faeces  *are  quite  thin  or  soft,  and  small  in  quantity, 
and  expelled  with  comparative  ease,  and  with  but  little  pain 
even  through  a  small  orifice.  This  immunity  from  imme- 
diate difficulty  and  danger  will  not  always  exist,  however  ;  for 
as  the  child  advances  in  years,  the  f;»ces  becon:ie  more 
abundant,  more  consistent  or  solid,  and  consequently  more 
difficult  to  expel  through  a  small  aperture — hence  it  is  highly 
important  to  treat  those  cases,  at  an  early  period,  even  if 
there  should  exist  but  slight  obstruction  to  defecation,  for  the 
evil  consequences  resulting  from  such  neglect,  in  the  after 
life  of  the  little  patient,  should  never  be  lost  sight  of.  M. 
Boyer  relates  two  very  interresting  cases  of  this  character,  in 
wliicli  the  congenital  narrowing  had  been  either  overlooked 
or  neglected  in  infancy.  One  was  a  male  eighteen  years  of 
age,  the  other  was  a  female  thirty-four  years  old.  Both 
were  cured  by  incision  and  dilatation,  and  both  sufi'ered 
severely  every  day  of  their  lives  previously.     {Traite  des 


G6  TilK    FIRST   SPECriOS    OF    M  \LFOKMATION. 

Maladies   Chirurgicales.  tome.  F/.j^.  406.  P«m,  1S49.  Cin- 
quicme  Ed.) 

7.  In  extreme  congenital  narrowing  of  the  anal  orifice,  in 
which  the  contraction  is  so  small,  rigid  and  unyielding,  that 
it  would  be  most  difiicult  if  not   absolutely  impossible   to 
insinuate  even  a  small  probe,  incision  is  essential  to  success, 
especially  if  considerable  time  has  been  suffered  to  elapse, 
and  the  symptoms  have  become  urgent.     Here  the  process 
by  dilatation  alone,  is  too  slow,  as  the  child  is  in  imminent 
danger  of  perishing  from  the  effects  of  the  accumulation  and 
the   retention   of    the  meconium    and    other   matters,   and 
requires  immediate  relief.     The  indication  in  such  a  case  is 
to  make  one  or  two  lateral  incisions  of  just  sufficient  extent 
to  afford  complete  exit  to  the  contents  of  the  intestines ;  to 
keep  the  orifice  and  canal  pervious  by  the  use  of  soft  tents 
and  subsequently,  if   necessary,  to   complete   the   cure   by 
dilatation.     A  slight  incision  on  each  side  should  first  be 
made  with  the  sharp-pointed  bistoury  to  allow  a  passage  to 
the  pent  up  feecal  matters ;  an  enema  of  warm  flax-seed  tea 
should  then  be   administered  so  as  to  unload  the   rectum 
completely,  and  afterwards  the  incisions  should  be  enlarged 
if  necessary,  by  the  probe-pointed  bistoury,  either  with  or 
without  the  director,  according  to  the  extent  of  the  contrac- 
tion.    If  the  director  is  used,  it  should  be  introduced  to  the 
depth  of  from  five  to  eight  lines,  with  the  bistoury  carried  on 
its  groove,  its  handle  drawn  outwards,  that  the  extremity'  of 
its  blade  may  press  in  the  groove  of  the  director ;  and  then 
it    should    be    drawn    obliquely   downwards   and   outwards 
toward  the  ischiatic  tuberosity  in  such  a  manner  that   the 
inferior  part  of  the  incision  may  extend  out  from  two  to  four 
lines  from  the  verge  of  the  anus.     The  opposite  side  should 
in  like  manner  be  operated  on.     In  making  these  incisions 
care  should  alwavs  be  taken,  not  to  extend  them  out  too  far 
lest  all  the  muscular  fibres  of  the  spliincter  be  cut  across, 
causing  them  to  retract  and  pulling  the  edges  of  the  incision 


♦ 


THE   FIKST   SPECIES   OF   MALFORMATION.  67 

too  far  from  each  other,  and  thus  giving  rise  to  an  ever  after, 
or  long  continued,  troublesome,  involuntary  discharge  of 
fseces.  To  avoid  this  great  evil,  some  of  the  muscular  fibres 
should  always  be  left  undivided,  and  the  cure  finished  by 
dilatation.  In  order  to  prevent  the  reunion  of  these  divided 
parts  and  to  keep  the  orifice  and  canal  pervious,  tents  made 
oi patent  lint,,  well  besmeared  with  simple  cerate,  or  dipped 
in  glycerine  should  be  introduced,  kept  in  situ  by  the  T 
bandage,  and  removed  frequently  and  fresh  ones  inserted. 
After  using  the  tents  for  several  days,  the  bougies  should  be 
used  daily  until  the  orifice  and  canal  are  sufficiently  dilated, 
and  the  cure  completed. 

8.  I  wish  it  distinctly  understood  that  I  protest  against 
incision  except  in  exti-emely  urgent  cases ;  for  it  is  an  indu- 
bitable fact  that  the  smallest  contraction  may  sooner  or  later 
be  overcome  by  gradual  dilatation ;  and  it  is  also  equally 
true,  that  even  after  incision  has  been  performed,  dilatation 
is  absolutely  necessary  in  almost  every  case  to  complete  the 
cure. 

9.  When  the  anal  stricture  is  the  result  of  a  riirid  or 
powerful  contraction  of  the  sphinctores  ani  muscles,  and  nu 
time  left  to  practice  dilatation  on  account  of  the  urgency  of 
the  symptoms,  a  division  of  some  of  the  fibres  of  those 
muscles  will  at  once  be  required :  in  all  the  instances, 
however,  in  which  it  exists  in  a  mitigated  form  dilatation 
will  relieve  it,  and  render  the  operation  of  division  unneces- 
sary 

10.  When  the  malfonnation  consists  of  an  extension  of  the 
marginal  integument  of  the  anus,  this  should  be  nicked  in 
several  places,  or  divided  in  several  places  with  the  probe- 
pointed  bistoury,  from  within,  outwards,  and  a  meche  of 
charpie  besmeared  with  simple  cerate  introduced,  and 
constantly  worn  for  several  days ;  then  the  bougie  should  be 
used  until  the  cure  is  finally  accomplished. 

11.  The  syphilitic  contraction  of  the  anus  will  generally 


68  Tim  FIRST  SPECIES    OF   JIALFOKSrATKMST.. 

yield  to  an  alterative  course  of  medicine,  such  as  the  nature- 
of  the  case  shall  denote  to  be  neeessaiy.  The  local  difficulty 
disappears  as  the  constitution  is  restored  to  health.  Soothing 
emollient  applications  are  the  best  topical  remedies.  Should 
there  be  any  excoriation  or  ulceration  about  the  part,  the 
surface  should  be  slightly  stimulated  daily  by  a  solution  of 
the  nitrate  of  silver,  or  by  the  ordinary  mercurial  lotions^  the' 
black  or  the  yellow  wash^ 


SECTION      III. 

CASES    AND     REMARKS. 

Case  i. — On  the  21st  of  January^  1848, 1  was  called,,  at  the 
request  of  Mr.  W.  D.  Oreenwood,  to  see  a  large  and  healthy 
looking  male  mulatto  child,  three  days  old,  whose  motherj- 
Sai'ah  Fry,  was  a  free  woman  and  resided  in  an  alley  between 
Camp  and  Magazine  streets.  New  Orleans  ;  I  was  told  that 
the  child,  had  taken  quite  a  quantity  of  molasses  and  water 
to  purge  it ;  had  not  passed  more  than  a  tablespoonful  of 
any  thing  from  its  bowels  since  its  birth,  and  that  it  was  con- 
stantly making  fruitless  eiforts  to  do  so.  Upon  examination, 
I  found  the  situation  and  the  form  of  the  anus  to  be  normal, 
but  its  orifice  was  so  contracted  that  it  offered  almost  the 
same  resistance  to  the  expulsion  of  the  meconium  as  though 
it  were  completely  imperforate.  The  contraction  was  con- 
fined solely  to  tlie  verge  of  the  anus.  The  other  organs  were 
all  normal.  Vomiting  had  already  commenced  and  there 
was  considerable  tumefaction  of  the  hypogastric,  as  well  as 
of  the  anal  region,  the  cliild  being  quite  restless  and  rapidly 
becoming  dangerously  ill,,  from  the  retention  of  the  meconium 
and  gas,  and  the  distention  of  the  rectum.  I  at  once  deter- 
mined on  the  operation,  and  whilst  Mr.  Greenwood  held  the 
child,  properly  placed  upon  his  knees,  I  thrust  into  the  con- 
tracted anus  the  straight  shaii3-pointed  bistoury  and  made  an 
incision  on  the  right  side,  of  from  three  to  four  lines  in  extent. 
A  large  quantity  of  meconium  and  gas  at  once  followed  the 
withdrawal  of  the  instrument.  The  opposite  side  was  tlien 
incised  in  the  same  manner.     A  warm  enema  of  milk  and 


THK   TLRST   SPECIES   OF   MALFORMATION.  69 

•Kviiter  Avas  now  thrown  up  into  tlie  rectntn,  -wliicli  wns  soon 
followed  by  a  still  I'liilher  evacuation  ot"  nicconiiun  and  ijas  ; 
after  which  a  tent  nia<Je  of  lint  and  besmeared  with  simple 
cerate  was  introduced  and  the  child  placed  by  the  side  of  its 
mother  in  bed,  already  ranch  relieved.  The  haemorrhage 
was  (j^uite  inconsiderable.  The  after  treatment  advised  in 
this  chapter  was  strictlyfollowed  up,  and  at  the  end  of  ten 
■days  the  incisions  were  entirely  cicatrized,  leaving  a  suffi- 
ciently ample  anus  which  performed  its  natural  functions 
admirably  without  any  further  treatment. 

Case  II. — Mrs.  Spangler,  an  intelligent  German,  the  wife 
■of  a  poor  laboring  man  residing  on  Dauj)hin  street,  New 
Orleans,  brought  to  my  office,  on  the  20tli  of  February,  1852, 
a  quite  feeble  and  emaciated  female  infant  six  weeks  old  ; 
stating  tliat  from  its  bii'th  it  has  had  the  greatest  difficulty  in 
voiding  its  stools,  owing  to  the  anus  being  almost  closed.  I 
found  upon  examination  no  imperfection  whatever  of  the 
parts,  except  the  narrowing  of  the  anal  orifice,  which  extended 
a  few  lines  up  the  canal,  and  which  scarcely  admitted  the 
-end  of  the  common  pi-obe.  The  mother  informed  me  that 
her  child  never  had  an  evacuation  from  its  bowels  without 
struggling  and  crjang,  and  tliat  during  such  paroxysms,  quite 
a  swelling  in  the  anal  region  would  take  place,  and  that  the 
fluid  taeces  would  sometimes  be  forcibly  discharged  in  jets 
trom  the  little  orifice,  like  from  the  pipe  of  a  small  syringe. 
I  expressed  my  surprise  that  the  child  sliould  have  lived  so 
long  with  so  small  an  anal  opening  ;  when  she  remarked  that 
she  was  in  the  constant  habit  of  injecting  warm  water  into 
the  bowel  with  an  ear  syringe,  whenever  the  child 
-experienced  more  than  usual  difficult}^  in  voiding  the  fasces, 
and  that  she  frequently  inserted  a  knitting  needle  into  the 
orifice  in  order  to  remove  the  slightest  obstruction  that 
might  occur.  These  means  she  said  never  failed  to  cause  a 
tolerably  free  discharge  of  thin  fiEces,  especially  when  she 
made  pressure  with  her  fingers  on  each  side  of  the  anus.  It 
was  quite  evident  to  me  that  the  life  of  the  child  was  thus 
far  prolonged  by  the  use  of  these  important  and  judicious 
measures.  She  also  informed  me  that  three  of  the  physicians 
of  the  city  had  examined  her  child  and  had  proposed  the 
operation  by  incision,  but  that  she  had  in  the  most  positive 
manner  refused  her  consent. 

I  immediately  commenced  the  treatment  of  this  case  by 
dilatation,  using  for  this  purpose  the  wax  bougie  according 
to  the  directions  already  given  in  this  chapter.  By  assidu- 
■ouely  pursuing  this  course  for  four  weeks,  a  most  decided 


70  THE    FIRST    SPECIES    OF   MALFORMATION. 

improvement  bad  taken  place,  and  on  the  iirst  of  May,  ten 
weeks  from  the  commencement  of  the  treatment,  I  dismissed 
the  child,  cured.  Nine  months  afterwards  the  child  contin- 
ued welL 

Case  III. — E-oonhiiysen  mentions  the  case  of  a  femak- 
infant  four  months  old,  M'hose  mother  from  its  birth  had  con- 
stantly been  compelled,  in  consequence  of  the  smallness  of 
the  anal  orifice,  to  press  out  the  faecal  matter  with  her  hands^. 
The  orifice  however,  at  length  became  so  small  that  the  fseces 
could  no  longer  be  pressed  through  it.  Great  distention  of 
the  abdomen  soon  followed,  attended  with  violent  pains  and 
excessive  fever,  which  seriously  endangered  the  life  of  the 
child.  An  incision  with  an  abscess  lancet  was  at  once  made 
through  the  skin  surrounding  the  anus,  and  the  incision  fur- 
ther enlarged  with  scissors,  upon  which  a  large  quantity  of 
excrementitious  matter  was  discharged.  The  aperture  thus 
made  was  subsequently  kept  open  and  enlarged  by  the  use 
of  tents  made  of  lint  and  embued  with  some  mild  ointment,, 
and  the  child  soon  recovered.  {Medico- Chirurgical  Ohser- 
vations.  Translated ^rom  the  German.  Part  II.  Ohser- 
vation  2.  Also,.,  Appendix  of  Observations,  Part  IL 
Observation  I.     London :  1676.) 

Case  1Y. — The  celebrated  Soultetus  reports  a  case  of 
this  species  which  occurred  in  his  practice.  In  l&iO  he  was 
called  to  see  a  male  child,  son  of  a  citizen  of  Ulm,  the  anal 
orifice  of  whom  was  so  small  as  scarcely  to  admit  the  end  of 
a  slender  probe.  He  advised  a  surgical  operation,  but  the 
parents  of  the  child  were  unwilling  to  allow  him  to  perform 
it ;  consequently  he  attempted  the  dilatation  of  this  narrow 
orifice,  and  ultimately  succeeded  by  the  continued  use  of 
tents  made  of  the  roots  of  ^e^?5ia7i,  dipped  in  oil,  introduced 
and  suffered  to  remain  in  until  by  imbibing  the  moisture  of 
the  parts,  they  would  become  swollen  and  thus  enlarge  the 
almost  imperforated  anus.  Scultetus  mentions  having  known 
a  midwife  of  Patavia  who  was  in  the  practice  of  perforating 
the  anus  when  wholly  closed,  with  a  sharp-pointed  probe^ 
and  of  enlarging  the  opening  thus  made  with  tents  of  gen- 
tian roots.  {Armarrhentariunh  Chirurgieum.  Observatio, 
LXX VIL  ^.323.     Amstelmdami  :  1741.) 

I  would  hero  remark  that  various  substances  which  from 
their  nature  rapidly  increase  in  bulk,  by  attracting  or  imbi- 
bing fluids — such  as  the  GentiaJioe  radix,  sponge  tent,  cat-gut^ 


THE    FIRST    SPECIES    OF   MALFORMATION.  71 

&c.,  are  even  at  the  present  day  reconimendorl  in  tlie  treat- 
ment of  the  cases  under  consideration.  This  nictiiod  of  dress- 
ing, however,  simple  and  innocent  as  it  seems,  may  cause 
serious  accidents;  for  the  use  of  such  substances  in  such 
cases  is  by  no  means  void  of  dan^^er.  M.  Guersant  mentions 
a  case  in  which  an  operation  liad  been  performed  for  an 
imperforate  anus,  and  at  the  close  of  which  a  piece  of  pre- 
pared sponge  was  placed  in  the  wound,  and  suffered  to 
remain  too  long  in,  producing  peritonitis  and  subsequent 
death.  {Gazette  des  Hopitaux  de  Paris.  1857.  No.  LXX.]y. 
277.) 

Case  Y. — Mr.  A.  Copeland  Hutchison,  of  England, 
reports  the  following  case  of  contraction  of  tlie  anus,  with  a 
communication  of  the  rectum  with  the  vagina.  I  have 
classed  it  among  my  first  species,  although  in  reality  it  does 
not  belong  here.  "  My  friend,  Mr.  Barthurst,  of  Strood,"  says 
Mr.  Hutchinson,  "  had  a  case  where  the  faeces  came  per 
vaginam,  the  natural  anus  being  barely  sufficient  to  admit  of 
the  entrance  of  a  good  sized  probe,  but  communicating  witli 
the  gut.  By  gradually  dilating  the  natural  anus  with  bou- 
gies in  early  infancy,  the  faeces  were  expelled  with  as  much 
freedom,  after  a  certain  time,  as  if  the  passage  had  never 
been  closed  ;  and  what  is  remai'kable,  the  communicating 
aperture  in  the  vagina  experienced  a  spontaneous  cure.  The 
child  is  now,  (N"ovember  1825,)  ten  years  old.  {Practical 
Observations  in  Surgery,  'ind  Ed.  p.  257.  London.  1826.) 

Case  YI. — "The  expulsion  of  the  meconium,"  says  Cooke, 
translator  of  Morgagni,  "  is  sometimes  prevented  by  an  ex- 
tremely rigid  contraction,  so  that  a  probe  can  scarcely  be  in- 
troduced. A  child  was  brought  to  me  some  years  ago  with 
this  imperfection,  and  the  faeces  passed  through  the  vagina." 
{CooMs  Morgagni.      Vol.  II.  p.  110.     Boston:  1824.) 

Case  YH. — The  following  case  is  reported  by  Mr.  W.  Fer- 
gusson.  "In  a  new-born  infant,  brought  to  me  some  time  ago, 
tlie  opening  at  the  lower  part  of  the  rectum  was  so  small  that 
the  meconium  could  not  be  discharged  only  by  drops  ;  a  large 
collection  above  had  taken  place,  and  the  proti-usion  in  tlie 
perinaeum  was  considerable.  A  probe-pointed  bistoury  was 
introduced,  and  four  notches  were  made  which  permitted  a 


72  THE   riKST   SPECIES    OF   MALFOEMATION. 

copious  evacuation."  {A  System  of  Practical  Surgery^  'p-  5-15, 
Fhil. :  1853.) 

Case  YIII. — Mr.  T.  J.  Ashton  of  London  mentions  a  case, 
in  wliicli  it  appears  no  surgical  treatment  had  been  adopted 
until  the  child  was  two  years  old.  He  says,  "  Some  years 
since  I  saw,  in  conjunction  with  Mr.  Morton,  a  child  about 
two  yeai's  old,  with  congenital  contraction  of  the  anus,  which 
would  not  admit  a  larger  instrument  than  a  number  eleven 
bougie ;  the  belly  was  tumid,  and  the  general  health  im- 
paired. Dilatation  was  had  recourse  to ;  in  a  short  time  the 
bowels  could  be  entirely  relieved,  and  with  the  aid  of  tonics, 
the  patient  progressed  favorably."  {Diseases,  Injuries  and 
Malformations  of  the  Rectuiti  and  AnuSy  jp.  27.  London : 
ISoi.) 

Case  IX. — J)r.  Townsend,  Senr.,  saw  a  child  at  the  Massa- 
chusetts General  Hospital,  which  was  born  on  Sunday,  the  4th 
of  September,  1854,  and  which  had  an  imperforate  anus.  JN'o 
operation  was  permitted  on  it  at  that  time.  It  was  seen  again 
on  the  Thursday  following.  A  little  meconium  had  passed 
through  a  small  pin-hole  aperture.  A  probe  passed  in,  and 
the  opening  freely  dilated,  tlie  rectum  being  found  free.  The 
child  did  well.  {Becords  of  the  Boston  Society  for  Medical 
Improvement.      Vol.  11.  p>-^'^-     Boston:  1856.) 

Case  X. — Dr.  Seaverns,  of  Jamaica  Plain,  presented  to  the 
'■Boston  Society  for  Medical  Improvement^  through  J.  B. 
Jackson,  M.  D.,  September  13th,  1848,  a  specimen  of  con- 
erenital  stricture  of  the  anus.  The  child  died  at  the  age  of 
eighteen  months,  of  a  dysenteric  affection.  At  birth  the  open- 
ing was  only  large  enough  to  admit  a  probe.  It  was  gradually 
enlarged  by  the  aid  of  bougies.  The  intestine  above  the  stric- 
ture was  considerably  dilated.  {Records  of  the  Boston  Society 
for  Medical  Improvement.     Vol.  Ill  p.  270.    Boston:  1859.) 

Case  XI. — M.  Devilliers  met  with  a  case  in  his  practice, 
and  which  he  reported  to  the  "  Medical  Society  of  Paris,^''  of 
a  child  which  had  both  an  obliteration  of  the  anus  and  of  the 
uretln-a.  Upon  examining  the  child  with  care,  M.  Devilliers 
found  that  the  malformation  arose  from  ao-gluti nation  of  the 
integument  at  the  anus.  He  cautiously  separated  the  lips 
of  the  anus,  and  the  walls  of  the  rectum,  for  an  extent  of 
about  six  lines  with  his  right  index  finger,  then  using  a  grooved 
sound,  he  reached  the  point  where  the  meconium  was,  and 


TIIK   FIRST    SrECIES   OF   MALFORMATION.  73 

thus  conij)let(!ly  opened  the  passai^e.  lie  attempted  in  a 
siniihu-  nuumcr  to  overcome  the  agghitination  of  the  uretlira, 
hut  failed  ;  he,  however,  finally  suceeded  hy  the  aid  of  a  small 
sound.  The  child  died  iiftcen  days  after.  No  autopsy.  {lie- 
vue  Mcdicale  de  Paris.    Mai,  1835.^^.  280). 

Case  XII. — The  following  case  was  reported  to  the  "  Pen- 
insular Journal  of  Medicine  and  tiie  ColUxteral  Sciences,"  by 
S.  L.  Andrews,  M.  D.  "  In  a  private  letter  from  my  friend, 
Dr.  Baldwin,  of  Lahaina,  Sandwich  Islands,  I  have  an  in- 
terestinsj^  account  of  a  case  ot  congenital  contraction  of  the 
intestinal  canal.  As  Dr.  B.  has  given  me  the  case  more  in 
detail  than  is  needful  for  your  Journal,  I  have  abridged  it  for 
your  use.  The  child,  a  fine-looking,  plump  female,  weighing 
8i|-  lbs.,  was  born  Dec.  5th,  1838.  The  first  indication  of  any- 
thing abnormal  was  the  rejection  of  a  little  sweetened  water 
given  a  few  hours  after  birth.  On  the  following  morning 
castor  oil  was  rejected  with  bilious  vomiting.  A  judicious 
use  of  cathartics,  including  suppository  and  enemata,  the  lat- 
ter sometimes  administered  through  a  gum-elastic  catheter 
introduced  several  inches  into  the  rectum,  failed  to  produce 
any  adequate  evacuation  of  the  bowels.  Castor  oil  and  other 
cathartics,  and  sometimes  enemata,  only  excited  vomiting, 
usually  bilious.  At  length,  the  contents  of  the  intestines,  in 
a  very  offensive  state,  were  thrown  off  by  vomiting.  All  that 
was  passed,  per  anum,  was  fragments  of  hardened  meconium, 
shaped  to  the  intestines,  and  amounting  to  several  inches  in 
length.  The  last  fragment  tapered  to  a  point  at  its  upper  ex- 
tremity.    Death  on  the  13th. 

'•  Diagnosis,  contraction  of  the  intestine,  which  was  con- 
firmed by  the  autopsy. 

"The  rectum  and  colon  were  about  half  the  natural  size,  or 
perhaps  a  little  more,  except  a  portion  in  the  middle  of  the 
arch,  where  it  was  reduced  to  about  half  the  diameter  of  that 
on  each  side  of  it.  The  caecum  was  natural,  but  for  twelve 
inches  above  it  the  small  intestine  was  small  indeed,  not 
larger  than  the  narrowest  tape,  and  the  canal  too  narrow  to 
admit  anything  solid  ;  the  next  six  inches,  proceeding  towards 
the  stomach,  was  very  narrow,  but  contained  a  few  small 
pieces  of  hardened  meconium.  Eighteen  inches  above,  this 
was  larger,  but  crowded  with  viscid  meconium.  The  re- 
mainder of  the  intestine  to  the  stomach  was  twice  the  natural 
size.  The  gall-bladder  was  large  and  full.  The  stomach  and 
upper  part  of  the  intestine  was  filled  with  a  liquid  appearing 


74  THE   FIRST   SPECIES    OF   MALFORMATION. 

like  a  mixture  of  bile  and  milk.     The  child  had  nursed  until 
the  last  day. 

"The  father  of  the  child,  an  efficient  and  devoted  missionary 
under  the  American  Board,  has  disproportionately  short  limbs, 
both  upper  and  lower.  He  is  also  afflicted  with  exostosis.  A 
sister  is  afflicted  in  the  same  manner,  and  some  of  the  children 
of  both  brother  and  sister  have  the  same  morbid  state  of  the 
bones." — {Peninsular  Journal  of  Medicine  and  the  Col- 
lateral Sciences.  1839.) 


CH^I^TER    III. 

THE  SECOND  SPECIES  OF  MALFORMATION. 
SECTION    I. 

DESCRIPTION. 

1.  This  species  of  malformation,  «^ym«  orificu  arid,  is  char 
acterized  by  the  closure  of  the  anal  orifice  by  a  thin  transpa- 
rent membrane,  somewhat  resembling  the  hymen,  through 
which  the  meconium  may  often  be  seen,  yet  sufficiently  strong 
to  prevent  its  escape  from  the  rectum.  This  membrane,  or 
cutano-mucous  lamina,  however,  is  sometimes  quite  thick  and 
hard,  and  simulating  the  common  integument  of  the  anal 
region. 

2.  This  vice  of  conformation  is  readily  indicated  by  a 
small  soft  and  fluctuating  hemispherical  tumor,  usually 
observed  several  hours  after  birth,  at  the  natural  situation  of 
the  anus,  caused  by  the  pressure  of  the  accumulated  meco- 
nium and  gas  against  the  occluding  membrane.  It  may  also 
be  easily  distinguished  too,  by  the  yielding  of  the  prominence 
to  the  pressure  of  the  fingers,  and  then  projecting  again 
when  the  pressure  is  removed  ;  by  the  tumor  becoming 
larger,  firmer  and  more  ap]3arent  whenever  the  child  cries* 
struggles,  or  makes  efltbrts  to  expel  the  contents  of  the 
bowels  ;  by  a  fluctuation  more  or  less  evident,  as  well  as  a 
cavity  which  can  be  distinctly  felt  under  the  occluding 
membrane  ;  and  lastly  by  a  bluish  or  livid  spot,  usually  in 
the  centre  of  the  prominence,  indicating  clearly  the  position 
of  the  anus.     Fabricius  ab  Aquapendente  in  describing  the 

same  deformity  says  :  '•  Msi  ani  locus  velliGula  abductus  est 

75 


70  THE    SECOND    SPECIES   OF   MALFOEMATION. 

tamen  orificii  vestigium  et  taiujentibus  persentitur  vaeuum 
intus.''^  {Opera  Chirurgica,  part  1.  Cap.  88.  Patav.  1617, 
I'olia.) 

3.  This  species  of  malformation  is  the  most  simple  form  of 
arrested  development  pertaining  to  the  anus,  and  it  is 
doubtless  the  most  frequent,  yet  if  the  number  of  cases  on 
record  are  to  be  taken  as  evidence  of  this  fact,  it  fails  entirely 
to  establish  it,  for  there  are  indeed  but  few  cases  reported. 


SECTIOIT      II. 

TREATMENT. 

1.  The  anus  and  the  rectum,  in  this  species  of  malformation 
are  most  always  well  formed,  including  the  ^phinctores  ani 
muscles,  the  only  imperfection  being  the  membranous 
closure  of  the  anal  orifice  ;  consequent!}'-  the  surgical  measures 
recommended  for  the  relief  of  this  impediment  are  simple 
and  uniformly  successful,  if  timely  adopted. 

2.  The  treatment  consists  of  a  puncture  and  a  crucial 
incision.  The  straight  sharp-pointed  bistoury  should  first  be 
plunged  into  the  most  prominent  part  of  the  tumor,  in  the 
direction  of  the  rectum,  through  the  occluding  membrane  to 
the  seat  of  the  meconium ;  or  into  the  presumed  centre  of 
the  anus  indicated  most  always  hy  the  livid  spot.  This 
puncture  will  afford  an  exit  to  tlie  contents  of  the  intestine, 
and  by  their  evacuation  the  most  urgent  symptoms  will  at 
once  be  relieved.  The  puncture  thus  made  should  then  be 
sufficiently  enlarged  in  the  antero-posterior  and  transverse 
direction  with  the  probe-pointed  bistoury,  cutting  the  mem 
brane  from  witlun  outwards  ;  and  if  it  be  very  thick  the 
angles  of  the  flaps  formed  by  the  crucial  incision  should  be 
seized  witli  the  forceps  and  excised  with  tlie  curved  cissors. 


THE    Ki:CO]Sfr>   SPECIES   OE   MALFORM4'riO:Sr.  77 

After  the  complete  eviiciuitioii  of  the  distended  rectnrn  hy 
warm  eiiemata,  a  tent  or  meche  of  lint  spread  with  simjde 
cerate,  or  dipped  in  olive  oil  should  be  introduced  into  the 
opening  and  renewed  from  time  to  time  until  complete 
cicatrization  has  taken  place.  It  is  scarcely  ever  necessary 
to  use  the  bougie  in  these  cases,  and  even  the  meche  of  lint 
may  often  be  dispensed  with,  after  the  sixth  or  seventh  day, 
as  there  is  generally  no  disposition  in  the  parts  to  contract 
too  nmch,  especially  if  the  membrane  has  been  thin,  and  the 
anus  well  formed  as  is  usually  the  case. 

3.  Professor  Hays,  of  Philadelphia,  the  very  able  and 
distinguished  editor  of  the  "  American  Journal  of  the 
Medical  Sciences,"  advises  the  operation  to  be  performed  at 
the  moment  when  the  infant  makes  efforts  to  expel  the 
contents  of  the  rectum,  and  the  membrane  is  most  tense. 
He  thinks  it  wholly  unnecessary  to  cut  off  the  angles  of  the 
membrane  formed  by  the  crucial  incision,  as  they  soon 
retract  towards  their  base  and  become  confounded  with  the 
margin  of  the  anus.  {Aineriean  Cyclo^CBdia  of  Practical 
Medicine  and  Surgery.  Vol.  II.  Article^  Imperforate  Anus, 
p.  151,  Phil. :  1841.) 

4.  Professor  Pancoast,  of  Philadelphia,  in  his  invaluable 
treatise  on  "  Operative  Surgery,"  says  that  the  employment 
of  bougies,  or  of  catheters,  after  the  operation  of  opening  the 
anal  orihce,  for  the  purpose  of  keeping  open  the  passage,  or 
enlarging  it,  is  not  unattended  with  dangei",  in  consequence 
of  the  soft  and  delicate  organization  of  the  mucous  membrane 
of  the  rectum,  at  this  early  age — hence  he  recommends  that 
the  newly  made  opening  should  be  preserved  patulous  by  the 
daily  introduction  of  the  finger  previously  oiled.  {Operative 
Surgery, p.  ^'dQ.   Phil.:  1841.) 

5.  M,  Levret  recommended,  in  these  cases  of  anal  occlusion, 
circumscribing  the  obstructing  membrane  by  a  circular  inci- 
sion.   This  operation,  however,  is  never  practised. 


78  THE    SECOND    SPECIES    OF   MALFORMATION. 

SECTIONIIL 

CASES  AND  REMARKS. 

Case  XIII. — In  February,   1840,  I  was  sent  for  in  haste 

by  Mr.  H of  Bourbon  County,  Kentucky,  at  the  request 

of  the  attending  midwife,  Mrs.  S to  see  his  child,  a  stout, 

healthy  boy,  forty-eight  hours  old.  It  appeared  that  in  conse- 
quence of  the  feeble  condition  of  Mrs.  11 ,  who  required 

a  great  deal  of  attention,  that  the  child  had  been  neglected, 
and  the  discovery  had  just  been  made,  that  it  had  not  passed 
anything  from  its  bowels  since  its  birth,  and  that  it  really  had 
no  anal  opening.  Upon  examination  I  found  the  anal  orifice 
completely  occluded  by  a  tolerably  thick  brownish  mem- 
brane, surrounded  by  considerable  puckering  of  the  adjacent 
integument.  The  obstructing  membrane  was  distended  by 
the  meconium  and  formed  a  soft  projecting  tumor  as  large  as 
a  filbert.  The  child  was  continually  vomiting  the  milk  as  fast 
as  taken  into  the  stomach,  and  its  abdomen  was  slightly 
swelled  and  tense.  It  was  perfect  in  other  respects,  and  urin- 
ated freely.  The  cliild  was  properly  placed  upon  its  back  on 
the  lap  of  the  midwife  who  held  it  firmly  with  its  thighs  eleva- 
ted and  nates  separated,  whilst  I  plunged  a  sharp-pointed  bis- 
toury into  the  centre  of  the  projection,  through  which  opening 
the  contents  of  the  bowels  were  at  once  discharged.  I  then 
with  a  probe-pointed  bistoury  enlarged  the  opening  by  incising 
the  membrane  from  within,  outwards  and  crucially ;  the  angles 
of  the  flaps  thus  formed  were  seized  with  the  forceps  and  ex- 
cised with  a  curved  scissors.  A  tent  of  lint  dipped  in  olive  oil 
was  now  introduced  into  the  newly  made  orifice  and  frequently 
removed  afterwards,  and  replaced  by  a  new  one,  until  the 
cure  was  complete,  which  took  place  in  less  than  three  weeks. 
To  my  surprise,  considerable  haemorrhage  occurred,  but  not 
suflicient  to  cause  any  bad  result.  In  this  case  the  occluding 
membrane  was  of  a  dark  brownish  color,  quite  elastic  and 
about  two  lines  in  thickness.  I  saw  this  boy  in  1854,  when  he 
had  attained  his  fourteenth  year,  and  he  had  as  well  formed 
an  anus  as  could  be  desired. 

Case  XIY.— Gunning  S.  Bedford,  M.  D.,  the  able  and 
distinguished  Professor  of  Obstetrics  and  the  Diseases  of 
Women  and  Children  in  the  Medical  Department  of  the  Uni- 
versity of  the  City  of  New  York,  mentions  a  case  of  occlusion 
of  the  anal  aperture.  A  male  child  one  week  old  was  brought 
to  the  Professor's  Gli7iique,  ajjparently  in  great  agony,  not  hav- 
ing had  anything  to  pass  its  bowels  since  its  birth,  refusing 


THE   SECOND    SPECIES    OF   MALFORMATION.  79 

tlie  breast  and  constantly  moaning,  I  prefer  presenting  a 
part  of  this  case  in  the  inimitable  style  of  the  professor  hini- 
eelf. 

"  That  is  not  your  child,  madam — is  it?  No  sir  ;  its  mother 
is  too  weak  to  come  out.  So  I  should  think,  my  good  woman. 
That  little  infant  is  rather  young  to  be  brought  here.  Yes 
Sir;  I  know  it  is,  but  the  poor  little  dear  suffers  so  much 
that  its  mother  begged  me  to  let  yon  see  it.  Well,  madam, 
we  will  do  what  we  can  for  it.  Are  you  certain  that  it  has 
not  had  a  passage  since  its  birth  ?  Oh  yes  Sir — I  know  it  has 
not.  Does  it  pass  its  water  ?  Yes  Sir.  Have  you  given  it 
any  medicine  ?  Indeed,  Sir,  it  has  taken  all  sorts  of  things. 
What  has  it  taken,  madam  ?  Molasses  and  water,  and  castor 
oil  and  rhubarb,  and — There  my  good  woman,  that  will  do. 
Why,  Sir,  I  have  not  told  you  half.  You  have  told  me  suf- 
ficient to  satisfy  my  mind  that  the  poor  little  infant,  young 
as  it  is,  has  passed  through  a  martyrdom  !  Does  that  child 
vomit  ?  Oh  yes,  sir  ;  for  the  last  four  days  it  could  not  keep 
anything  on  its  stomach.  Is  its  little  belly  large?  Oh  yes, 
Sir  ;  it  is  very  much  swelled.  Has  it  been  attended  by  a 
doctor?  Yes,  sir ;  and  he  said  the  child's  bowels  had  the 
torpids.  You  mean  torpor,  do  you  not,  madam  ?  Well,  Sir  ; 
it  was  something  that  way.  I  think  we  shall  discover,  my 
good  woman,  that  the  torpor  was  in  the  doctor's  brain." 

CFpon  examination  the  professor  found  a  complete  occlu- 
sion of  the  child's  anus,  which  at  once  accounted  for  the 
uon  evacuation  of  its  bowels. 

"  Madam,  it  is  not  necessary  for  me  to  tell  you  that  this 
child  is  in  a  very  dangerous  situation.  Oh,  no  Sir  ;  I  see  it, 
poor  little  dear.  There  is  but  one  thing,  my  good  woman, 
that  presents  the  slightest  ground  of  relief,  and  that  is  an 
operation.  What,  Sir ;  to  open  its  stomach?  jSTo  madam, 
we  do  not  open  stomachs  here — and  you  need  have  no  fear  of 
the  operation  of  which  I  speak.  Shall  I  do  what  I  think  is 
proper,  and  which,  in  fact,  is  the  only  thing  that  can  be 
done?  Yes,  Sir;  I  am  sure  the  poor  babe's  mother  will 
consent  to  anything.  What  I  propose  doing,  gentlemen,  is  to 
divide  by  a  simple  incision,  the  membrane  which  you  perceive 
has  caused  an  imperforation  of  the  anus." 

The  child  was  placed  on  its  back,  the  thighs  elevated  by  an 
assistant,  and  tbe  occlusion  being  well  exposed,  the  Professor 
with  a  bistoury,  made  the  incision  ;  and  immediately  a  large 
quantity  of  meconium  passed  from  the  bowels ;  the  tumefac- 
tion of  the  abdomen  became  very  much  diminished,  and  the 
infant's  countenance  gave  evidence  of  relief. 

"  In  order,  gentlemen,  that  the  incision  I  have  made  may 


so  THE    SECOND   SPECIES    OF   MALFOEMATIOX. 

be  kept  open,  it  will  be  necessary  for  a  day  or  two  to  intro- 
duce into  it  a  small  pledget  of  lint,  well  smeared  with  simple 
cerate ;  and  it  will  also  be  proper  to  throw  up  the  bowel  two 
wine-glasses  of  tepid  water  this  evening,  with  a  view  of  pro- 
moting a  free  evacuation," 

In  a  subsequent  lecture  the  Professor  alludes  to  the  same 
case  again  : 

"You  will  scarcely  recognise,  gentlemen,  in  this  infant,  the 
little  sufferer  brought  here  some  time  since  apparently  in  a 
moribund  condition.  To  be  frank  with  you,  1  am  surprised 
to  see  it  alive.  This  is  the  infant,  you  will  remember,  with 
imperforate  anus,  on  which  I  operated  when  it  was  about  a 
week  old.  At  the  time  when  I  performed  the  operation,  I 
very  distinctly  mentioned  that  such  was  the  low  condition  of 
the  infant,  I  could  make  no  assurance  of  a  successful  issue.  I 
am  now  agreeably  disappointed,  and  this  recovery  affords 
another  evidence  of  the  extraordinary  tenacity  of  life." 
{Clinical  Lectures  ofi  Diseases  of  Woman  and  Childt'en. 
Uh  Ed.    pp.  295,  325.     Wew  York :  1857.) 

Case  XY. — Mr.  Hutchison  relates  a  case  of  this  species  : 
"  A  male  child  one  day  old  was  brought  to  the  Westminster 
General  Dispensary  by  the  attending  midwife  ;  and  as  the 
gut  visibly  caused  a  protrusion  of  the  parts,  when  gentle 
titillation  was  made  over  the  situation  where  the  anus  sliould 
have  been,  which  was  marked,  the  point  of  a  lancet  was  intro- 
duced about  the  eighth  of  an  inch  or  upwards,  which  entered 
the  gut,  and  was  sufficient  to  liberate  the  contained  meco- 
nium. Tills  opening  was  afterwards  enlarged  with  a  bistoury; 
a  small  piece  of  lint  dipped  in  oil  was  now  introduced,  to  pre- 
vent the  sides  of  the  incised  wound  from  again  uniting ;  and 
the  infant  was  discharged  cured  in  about  three  weeks,  with  a 
well-formed  anus."  {Ojj.  cit.  p.  261.) 

Case  XVI. — ^The  following  case  of  simple  occlusion  of  the 
anal  orifice  was  reported  to  the  "  Suffolk  District  Medical 
Society  of  Massachusetts,"  by  E.  B.  Moore,  M.D. 

"  A  male  child  was  born  on  the  22d  of  jN^ov.  1853.  Where  the 
anal  opening  should  have  been,  there  existed  a  sac  projecting 
three-fourths  of  an  inch  from  the  body  of  the  child.  Dr. 
Moore  operated  three  days  after  birth  with  a  trocar,  and  after- 
wards dilated  the  opening  by  bougies,  beginning  with  one 
the  size  of  a  pipe-stem^  and  gradually  increasing  the  size 
until  one  three-fourths  of  an  inch  in  diameter  could  be  passed. 
December  3d,  eight  days  after  the  operation,  the  child  was 
dismissed  as  cured,     lie   has  been  generiilly,  and  is  now. 


THE   SECOND  SPECIES   OF   MALFORMATION.  81 

(1857)  well  and  hcai-tv."    {Boston  II  edhxil  and  SurgicalJour- 
ncd,  Vol.  L  VI L  2>.  510.     Boston,  1858.) 

Case  XVII. — M.  Billard  reports  tlie  following  case  of  sim- 
ple iinpcrforatidii  of  the  anus.  This  child  would  doubtless 
have  been  sav-ed  by  the  operation,  had  it  not  been  for  the 
gastro-eiiteritis. 

"  Grenel,  aged  two  days,  entered  by  the  Creche  [the 
Jiatno  given  to  the  apartment,  in  which  infants  are  depo- 
sited when  Urst  brought  to  the  liospital]  on  the  ninth  of 
March.  This  child  had  passed  no  meconium  since  birth  ;  the 
abdomen  was  tumid  and  very  painful,  for  the  child  cried  and 
the  fjice  became  pinched  whenever  the  abdomen  was  touched. 
Tiie  course  of  the  colon  could  be  felt  through  the  parietes  of 
the  abdomen.  He  vomited  green  substances  ;  the  cry  was 
feeble  ;  skin  cold  ;  and  the  circulation  very  slow.  The  anus 
was  imperforate,  although  there  existed  the  appearance  of  its 
orifice  in  the  perimeum.  I  passed  through  a  sharp-pointed 
bistoury,  being  careful  to  turn  the  back  towards  the  bladder, 
and  after  having  made  the  incision,  I  enlarged  it  in  a  back- 
ward direction.  A  large  quantity  of  meconium  immediately 
issued  from  the  opening ;  the  swelling  of  the  abdomen  at 
once  subsided,  and  the  pains  apparently  ceased,  for  the  child 
stopped  crying,  and  the  face  no  longer  exhibited  the  expression 
of  pain.  He  was  immersed  for  half  an  hour  in  a  bath  of 
marshmallows  ;  but  notwithstanding  all  these  precautions,  the 
vomiting  continued,  and  he  died  at  night. 

"  The  autopsy  :  On  examining  the  body,  a  passive  conges- 
tion of  the  pharj^nx  was  found,  and  on  the  mucous  membrane 
of  the  stomach  several  patches  of  a  vivid  red,  together  with  a 
universal  redness  and  tumefaction  of  the  inner  membrane  of 
the  small  intestines  ;  the  muciparous  follicles  were  very 
numerous  in  the  large  intestines  ;  the  circumference  of  each 
of  these  follicles  was  surrounded  by  a  red  circle  ;  the  rectum 
was  continued  to  the  perineeum,  where  it  was  only  closed  by 
a  simple  membrane.  A  large  quantity  of  meconium  \vas 
found  in  the  laro^e  intestines.     The  remainder  of  the   intesti- 



nal  tube  contained  some  yellow  adhesive  matters.  The  cir- 
culatory and  cerebral  systems  were  healthy."  {A  Treatise 
on  the  Diseases  of  Infants.  Stewart'^s  English  Version,  p. 
281.  JS'ew  York,  1839.) 

Cases  XVIII. — XIX. — Mr.  Ilowship  reports  the  two 
following  cases  of  simple  imperforation  of  the  anus. 

J^irst  Case. — "  S.  P.,  a  woman  aged  twenty-six  years,  was 
friglitened  in  the  eighth  month  of  her  pregnancv,  by  a  rat 
6         ^ 


82  THE    SECOND    SPECIES   OF   MALFOEMATIOX. 

leaping  repeatedly  at  lier.  Her  alarm  was  considerable,  but 
she  recovered,  and  went  her  full  time.  In  the  birth  the 
infant  was  observed  to  have  a  large  belly. 

"  On  the  second  day  after  the  child  was  born,  the  nurse 
observing  there  had  been  no  appearance  of  stool,  examined 
more  particularly,  and  found  there  was  no  passage.  The 
infant  was  therefore  taken  to  a  medical  person  in  the  neigh- 
borhood, who  with  a  lancet  divided  the  integument  that  cov- 
ered the  end  of  the  intestine.  Meconium  immediately 
appeared,  and  in  due  time  faecal  matter. 

"  The  evacuations  from  the  bowels  were  always  very  thin, 
nearly  black  and  extremely  offensive.  The  discharge  did 
not  appear  at  intervals,  as  in  common,  but  continually  oozed 
out  upon  the  napkins,  showing  there  was  no  power  of  reten- 
tion in  the  parts. 

"  In  six  months  the  child  was  again  taken  to  the  person  who 
had  punctured  the  intestine.  The  mother  said  that  she  was 
sure  the  passage  was  not  sufficiently  free.  The  surgeon,  how- 
ever, was  of  a  different  opinion,  insisted  upon  it,  '  that  every- 
thing was  right,'  and  giving  a  powder  for  the  infant,  sent  her 
away. 

"  When  the  child  was  able  to  run  alone,  it  was  still  neces- 
sary  to  keep  a  napkin    constantly  upon  him.      The  stools 
passed  without  his  knowledge,  he  was  well  enough  aware  of 
it  afterwards,  but  although  naturally  a  sharp  boy,  he  never 
was  conscious  of  it  at  the  moment  of  its  taking  place. 

"  His  belly  continued  to  enlarge,  and  when  a  year  and  a 
half  old,  it  had  formed  a  very  large  tumor,  but  unattended 
with  any  apparent  inconvenience.  The  appetite  was  so 
excessive,  that  it  amounted  to  a  constant  and  unnatural  crav- 
ing for  food.  He  was  perpetually  observed  to  pick  up,  and 
eat  whatever  might  be  lying  near  him  upon  the  ground,  small 
l)its  of  stick  or  broom  straws,  plum,  or  fruit  stones,  etc.  He 
seemed  never  to  be  satisfied,  but  would  eat  heartily,  every 
hour  through  the  day,  nor  did  anything  appear  to  disagree 
Nvirli  him. 

"  lie  had  been  seen  by  several  medical  gentlemen,  none  of 
whom  were  satisfied  as  to  the  particular  nature  of  his  com- 
phiint.  There  was,  indeed,  a  very  large  tumor  in  the  abdo- 
men, but  no  sensation  like  tliat  conveyed  by  a  collection  of 
water ;  nor  any  hardness,  or  particular  sensibility  about  the 
region  of  the  liver,  to  warrant  any  suspicion  of  hepatic 
disease. 

"  When  two  years  old,  the  child  was  still  suckling.  The 
niotlier,  from  his  peculiar  state  of  health,  considered  he  was 
not  strono;  enou2:h  to  be  weaned.     About  this   time   he   had 


THE   SECOND   SPECIES   OF   MALFORMATION,  83 

haen  out,  and  made  some  complaint  of  nneasiness  and  pain  in 
his  t)clly,  and  on  roturrn'nr^  home,  lay  di>wn  in  the  cradle, 
still  nnea.sy.  The  i'ollowing  (hay  lie  was  worse,  with  a  hot 
and  dry  skin,  white  tongue,  thirst  and  extreme  restlessness. 
Tiiere  was  now  a  constant  and  most  distressing  sense  gf 
uneasiness  in  the  helly.  In  the  night  he  would  creep  to  tlie 
edge  of  the  cradle,  and  partly  out,  he  would  hang  over,  rest- 
ing his  hands  on  the  lloor,  while  the  abdomen  was  pressed 
by  the  edge  of  the  cradle.  This  posture  appeared  to  give 
him  partial  relief." 

"  Tlie  i'ever  and  general  irritation  continued  to  increase  daily 
to  his  death,  Vv'hich  took  place  six  days  subsequent  to  the 
commencement  of  the  attack." 

"  Post-Mortem  Exammation. — The  abdomen  was  exceed- 
ingly enlarged.  On  cutting  into  the  cavity,  a  soft,  white, 
elastic  tumor  was  found.  This  tumor,  traced  by  its  connec- 
tions, proved  to  be  the  lower  part  of  the  intestine  rectum. 
The  stomach  and  small  intestines  were  healthy,  but  the 
whole  of  the  great  intestine  was  enlarged  to  at  least  double 
its  natural  size. 

"  Just  where  the  rectum  commences,  the  coats  of  the  in- 
testine were  suddenly  expanded,  forming  a  great  oval  pouch, 
or  bag,  sufficiently  large  to  contain  three  pints  of  fluid.  The 
structure  of  this  bag  was  more  dense  and  strong  than  that  of 
tlie  intestine  in  its  natural  state. 

"  The  contents  of  this  bag  were  a  very  large  quantity  of  fruit 
stones,  with  bits  of  stick,  straws  and  dirt ;  together  with  a 
large  collected  mass  of  fluid,  dark  fgecal  matter,  M-ith  which 
the  whole  of  the  colon  was  more  or  less  filled,  as  well  as  the 
large  sac  that  contained  the  stones. 

"  The  enlargement  of  the  rectum  had  extended  itself  quite 
down  to  the  anus,  so  that  to  remove  the  tumor  entire,  it  be- 
came necessary  to  dissect  out  part  of  the  integuments  which 
formed  the  artitical  anus.  The  latter  opening  was  found  to  be 
so  confined,  that  it  was  with  difficulty  a  bougie  of  middle 
size  could  be  pushed  through  it.  This  opening  consequently 
could  give  passage  only  to  the  thinnest  kind  of  faacal  matter." 
{Practical  Ohservations  in  Surgery  and  Morhicl  Anatomr/.  p. 
317.   London:  1816.) 

Second  Case. — "  A  medical  friend,  Dr.  Samuel  Merriman," 
says  Mr.  Howship,  "to  whom  I  mentioned  the  above  case, 
acquainted  me,  that  he  had  seen  an  instance,  which  he  be- 
lieved to  be  of  a  very  similar  nature  with  the'preceeding  one. 
A  child  was  born  with  imperforate  anus,  and  an  enlarged 
abdomen.     The  integuments  were   punctured  with  a  trocar, 


S4  THE   SECOND    SPECrES    OF  IVfALFDEl^rATION'. 

the  meconium  first  appeared,  and  ftjecal  matter  subseqnentljr„ 
It  was  intended  in  this  instance,  to  have  formed  an  enhirged- 
and  adequate  orifice  by  the  nse  of  bougies,  or  such  other 
means  as  might  liave  been  necessary ;  bat  the  mother,  botb 
ignorant  and  obstinate,  was  not  to  be  prevailed  upon  to  allow 
any  thing  more  being  done  on  tlie  child's  behalf-  The  infant 
went  ott  tolerably  well  for  about  six  months,  althouigh  the- 
enlargement  of  the  abdonaen  continued  to  increase.  He  sub- 
sequently became  poorly,  and  died.  The  body  was  not  ex-^ 
amined."     {Loe.  cit.  ;p.  320.) 

Cases    XX.  —  XXI. — M,  Di^areque  records  two  cases- 
of  this  species  of  malformation  upon  which  he  operated. 

The  first  case  was  that  of  a  child  which  had  not  passed 
meconium  for  thirty-six  hours  after  birth.  M.  Bnpareque 
having  acertained  that  there  was  imperforation  of  the  anus,, 
opened  it  with  great  success.  {Bevvoe  Medicale  de  Paris. 
J/cn',  1835.  jt?.  284.) 

M.  Dupareque's  second-  case  was  a  child  to  which  he  was- 
called  in  consultation,  and  wliich  for  thirty  hours  after  Birtli 
had  ])assed  no  meconium.  M.  Duparque  having  acertained 
that  there  was  imperforation  of  the  anus,  succesfully  per- 
formed the  operation  with  a  strait  and  narrow  bistoury,  A 
gum-elastie  canula  was  placed  in  the  rectum.  Twelve  or 
fifteen  hours  afterwards,  all  the  signs  of  eflfu'sion  of  the  ab- 
domen manifested  themselves,  and  the  child  succumbed.  At 
the  autopsy  the  rectum  was  found  to  be  softened  and  punc- 
tured at  the  point  of  union  with  the-  sigmoid  flexure  of  the 
colon.  This  accident  was  produced  by  the  gmu-elastic  canula, 
which  from  carelessness  by  the  nurse  had  been  too  far  ad- 
vanced, and  kept  too  long  in.     {Loc.  dt.  jp.  285.) 

This  case  should  be  a  warning  to  both  surgeons  and  nurses- 
how  they  use  canulas  and  bougies.  In  my  opinion,  the  canula 
was  by  no  means  indicated  in  this  instance,  and  should  not 
have  been  used.  Soft  tents  with  the  occasional  use  of  the 
little  finger  were  all  that  were  i-equired  to  keep  the  passage 
patulous.  Several  cases  in  which  similar  accidents  have  occur- 
red from  the  careless  manner  of  usiug  canulas  and  bougies  will 
be  found  recorded  elsewhere  in  this  work. 

Case  XXIL — M.  Petit  reports,  with  several  otliers,  the 
case  of  a  cliild  presenting  an  imperforate  anus,  in  which  no 
sign   of  such   an   organ  was  visible.     On  the   third  day  the 


THE    SECOND    SPECIES    OF   MALFORMATION,  85 

mcinbrano  elosini:;  the  anns,  wliieli  was  both  thick  and  firm, 
was  incised  by  iiiin  with  a  hanoet.  The  inecoiiium  passed, but 
the  child  died  in  coiividsions.  {Memoir-e  deV AeademieJivyal/G 
U  Clvirunjie  de  Paria.  tome  II.  ]).  237.     1781.) 

Cask  XXIII. — M.  Petit  m\  another  occasion  witnessed  a 
new-born  child  which  was  destitute  of  an  anus,  or  any  sign 
of  one-  lie  first  attempted  to  incise  the  membrane  which 
covered  tlie  anus,  with  a  hmcet,  but  failed.  He  then  empk)yed 
a  trocar,  when  the  meconium  passed  out  freely ;  nevertheless, 
the  infant  died  on  the  ft^llowing  day.    {pj>.  cit.) 

Cask  XXIY.' — M.  Saviard,  Mdio  was,  at  the  time,  chief 
•surgeon  of  the  Hospital  Hotel  Dieu,  in  Paris,  relates  a  case 
of  simple  occlusion  of  the  annal  orifice. 

"  On  the  16th  of  Kovember,  1693,  an  infant  four  days  old 
was  brought  to  tlie  Hotel  Dieu,  whose  anus  was  closed.  Sa- 
viard examined  the  place  where  the  natural  aperture  ought 
to  have  been,  and  perceived  a  membrane  extended  across"  it, 
through  which  he  could  distinguish  the  meconium  by  its  dark 
fiolor.  He  incised  this  membrane  with  a  strait  sharp-pointed 
bistoury,  which  afforded  a  passage  to  the  contents  of  the 
bowels.  After  this  he  dressed  the  wound  three  days  with  a 
tent  dipped  in  digestive  to  prevent  its  reunion,  and  the  child 
was  cured."  {Nouveau  Reoueil  d^ Observations  Chirurgicales. 
Ols.iri  Park:  1702.) 

Case  XXY. — The  following  account  of  a  case  of  mon- 
strosity, having  a  closure  of  both  ears,  an  imperforate  anus, 
and  a  double  fissure  of  the  palate,  was  received  from  W,  Otis 
Johnson,  M.  D.,  of  Cambridge,  Mass.,  and  read  to  the  Boston 
Society  for  Medical  ImprovemeM,  July  12th,  1858,  by  Jeffries 
Wyman,  M.  D.,  who  also  showed  easts  of  the  ears. 

"  On  the  16th  of  June,  185S,  I  was  called  early  in  the  after- 
noon to  Mrs.  F.,  an  intelligent  woman,  wife  of  a  respectable 
zVmerican  mechanic.  In  half  an  hour  she  was  easily  delivered 
of  her  third  child.  The  first  is  living  and  is  an  unusually  hand- 
some girl  of  about  five  years;  the  second  died  before  the 
family  came  to  Cambridge.  Mrs,  F,  had  previously  told  me 
that  she  had  continued  to  nurse  her  second  child  three  montlis 
;after  her  last  conception,  which  of  course,  there  is  reason  to 
4oubt,     She  considered  her  '  time  '  as  at  hand. 

"  The  '  monster'  gave  no  signs  of  life  for  more  than  a  minute 
•f'cfter  birth,  and  was  what  is  professionally  called  hlue.  The 
.coi'd  was   about  the  neck.     In  about  tifteeu  minutes  after 


S6  THE    SECOND    SPECIES    OF   MALFORMATION. 

birth,  having  in  the  mean  time  made  but  a  few  faint  cries,  he 
gave  out  some  half  a  dozen  of  the  most  unearthly  shrieks  for 
an  infant  I  ever  heard.  These  were  repeated  some  eighteen 
hours  afterwards. 

-'  I  found  the  ears  closed  and  undeveloped^  as  your  casts 
will  show  ;  a  double  fissure  of  the  palate,  and  an  imperforate 
anus.  The  ensemble  of  the  features  was  idiotic  ;  the  remain- 
ing development  was  perfect,  and  seemed  to  be  that  of  a  six 
months'  or  six  and  a  half  months'  foetus. 

''Thirty-six  hours  after  birth,  a  fihn,  of  apparently  mucous- 
membrane  protruded  from  the  anal  fissure,  and,,  after  reaching 
the  size  of  about  half  an  inch  in  diameter,  burst,  and  meco- 
nium escaped. 

"  The  child  continued  to  show  an  increasing  vitality  till 
about  the  thirtieth  hour  after  birth,  from  which;  time  it  began 
to  sink,  and  died  easily,  forty -live  hours  after  birth."  {Records 
of  the  Boston  Society  for  Medical  Improvement,  Vol.  III. 
p.  214.    Boston :  1859.) 

Case  XXVI. — Ruysch  saw  a  child  whose  anus  was  closed 
by  a  membrane.  On  the  fifth  day  after  its  birth  there  was  a 
spontaneous  rupture  of  the  occluding  membrane  and  death 
soon  followed.  {Adversaria  Anatomica,  decad.  II.  Cajy.  10, 
p.  13.) 

Case  XXYII. — Von  Ammon  reports  the  case  of  a  male 
eliild  in  whom  there  existed  an  imperforation  of  the  anus  by 
a  simple  membrane  which,  he  at  once  incised.  In  this 
instance  there  was  quite  a  depression  at  tlie  natural  situation 
of  the  anus,  and  what  was  remarkable,  the  penis  was  in  a 
constant  state  of  priapism  which  continued  until  after  the 
operation  of  incising  the  occluding  membrane,  and  the 
complete  evacuation  of  the  rectum. 

This  child  was  well  formed  in  other  respects  and  lived  four 
months  after  the  operation,  the  anus  and  the  rectum  perform- 
ing their  functions  admirably,  the  sphiuctores  ani  being- 
present  and  well  formed.  The  child  died  of  a  scrofulous- 
diarrhoea.  {D-le  Angehorenen  Ckirurgischen,  KranTcTieiten 
Des  Menschen,    S.  4A.     Berlin,  1S4:±)      [Vide  Plate.  III.] 

The  following  authors  have  also  seen  and  described  cases 
of  this  peculiar  species  of  malformation. 

Fabricius   of  Hildanus.     {Ohsei^atiomtm    Chirurrjicarum 
Genturia..     Cent.  1.  Ohser.  73,  p.  51.     Basil^  160G.     Folia.)/ 
Fabricius  ab  Aquapendente.     {0^.  cit^- 


TUE   SECOND    SPECIES   OF    MALFOliMATIOX.  87 

Villi  Meeckrcn.     [Olservationes  Medico-Chirurgka.  cap. 
XXIV.  p.  114.  Amstelod,  1G82.     8w.) 

Littre.     {ITistoire  de  V Academic Royale  des  Sciences,  annee 

1710,^.47.) 
"Wagner.     {Commer,  Utierar.     Xorimherg,  p.  3G1,  annee 

1735.) 
Motais.     {Mernoires  de  V Academic  des  Sciences.,  annee  1771, 

p.  5T9.) 


CT3:-A.P»TEIl    IV. 

THE    THIRD    SPECIES    OF    MALFORMATIOIS. 

SECTION      I. 

DESCRIPTION. 

Atresia  Ani  et  Intestini  Recti.  In  this  si^ecies  of  arrested 
development  the  rectum  does  not  descend  as  low  in  the  pelvis 
as  it  should,  but  terminates  abruptly  in  some  form  of  cul-de- 
sac,  at  a  variable  distance  above  its  natural  outlet,  and  either 
hangs  loosely  in  the  pelvic  cavity,  or  adheres  to  the  anterior 
surface  of  the  sacrum,  or  to  the  bladder,  or  to  some  contig- 
uous part.  ISTo  anus  exists,  and  there  is  generally  not  even 
the  trace  of  an  anus  to  be  observed  in  situ  naturali^  the 
perinseal  raphe  being  extended  from  the  scrotum  to  the  point 
of  the  coccyx  without  interruption.  [  Yide  Plate  lY.,,  Fig.  1.] 
The  space  which  should,  have  been  occupied  by  the  anus  and 
the  absent  portion  of  the  inferior  extremity  of  the  rectum,  is 
filled  with  some  intermediate  substance  of  a  cellulo-fibrous 
nature. 

This  is  truly  a  deplorable  form  of  congenital  imperfection, 
especially  should  a  considerable  portion  of  the  inferior 
extremity  of  the  rectum  be  deficient ;  then  indeed  the  case 
becomes  most  serious  and  embarrassing  to  the  surgeon,  as 
there  are  no  external  signs  by  which  he  can  ascertain  posi- 
tively where  the  end  of  the  rectum  can  be  found,  or,  indeed, 
whether  the  organ  even  exists  at  all  or  not ;  and  to  add  fur- 
ther to  the  perplexity  and  the  difficulty,  the  rectum,  besides 
being  abnormal,  sometimes  occupies  an  abnormal  position. 
In  all  these  respects,  it  will  be  observed  that  this  species  dif- 


TIIIO   TIIIUI)    SPECIES    OF   MALFORMATION.  89 

fers  most  widely  from  the  second  species,  in  wliicli  a  swelling, 
a  fluctuating  tumor,  or  an  accompanying  projection  or  depres- 
sion in  tlic  natural  situation  of  the  anus,  indicates  the  exist- 
ence and  the  position  of  the  rectum,  and  directs  the  surgeon 
at  once  where  to  find  it. 

From  the  nunihcr  of  cases  of  this  species  which  are  re- 
corded, and  which  I  have  presented,  it  might  he  inferred, 
that  it  is  much  more  common  than  the  first  and  second 
species  ;  but  this  would  by  no  means  be  a  rational  conclusion, 
inasmuch  as  such  cases  scarcely  ever  escape  notice,  and  are 
doubtless  every  one  of  them  reported,  both  on  account  of 
their  formidable,  as  well  as  their  peculiar  character. 


SECTION     II. 

PHYSICAL  EXPLOKATION— DIAGNOSIS. 

In  these  cases,  in  which  there  is  no  external  indication 
whatever  of  either  an  anus  or  a  rectum,  it  is  of  the  utmost 
importance  to  success,  that  a  minute  and  careful  exploration 
should  be  made  as  a  preliminary  step  to  the  treatment. 

The  index  finger  of  the  right  hand  should  be  placed  in  the 
normal  position  of  the  anus,  and  pushed  firmly  np  tow\^rds 
the  pelvic  cavity  in  the  direction  of  the  rectum,  whilst,  at  the 
same  time,  with  the  left  hand  firm  pressure  upon  the  anterior 
walls  of  the  abdomen,  should  be  made,  both  inward  and 
downward  towards  the  finger  in  perinsieo.  In  this  manner  the 
ajjproach  of  the  rectum  towards  the  index  finger,  may  be 
detected  if  it  exists. 

Sometimes  by  the  finger  alone  in  the  perinseum  the  fluctua- 
tion of  the  distended  end  of  the  rectum  can  be  detected, 
should  it  not  be  too  far  distant. 

After  having  made  an  incision  of  the  ]3roper  depth  in  the  di- 


90  Tin:    TllliU)    SPECIKS    OF    ^[ALFOKMATIOX. 

rectiou  of  the  rectiim,  without  discovering  the  end  of  it,  the  in- 
dex finger  of  one  hand  should  be  introduced  to  the  bottom  of 
the  incision,  whilst  with  the  other  hand,  or  the  hands  of  an 
assistant  placed  upon  the  anterior  walls  of  the  abdomen,  the 
intestines  should  be  pressed  down  into  the  pelvic  cavity.  In 
this  manner,  if  the  rectum  exists,  it  might  be  detected  by 
the  fino;er  in  the  wound. 

.  In  these  cases  auscultation  and  percussion  may  also  be  used, 
in  order  to  discover  the  presence  or  absence  of  the  rectum. 
The  stethoscope  should  be  applied  to  the  perinseum,  and  at 
the  same  time  percussion  should  be  made  upon  the  walls  of 
the  abdomen.  By  these  means  the  presence  of  the  rectal 
exti*emity  filled  with  gas  and  fsecal  matter  may  be  dis- 
covered. 

In  arriving  at  a  correct  diagnosis  in  these  obscure  cases,  con- 
siderable aid  will  be  afi'orded  by  the  introduction  of  the  sound 
into  the  bladder,  if  possible,  or  into  the  vagina.  Tlirough 
these  media  much  may  be  discovered  in  relation  to  the  exist- 
ence and  the  exact  locality  of  the  blind  sac  of  the  rectum. 

Mr.  A.  Copeland  Hutchison  recommends  in  these  cases, 
gentle  titillation  of  the  skin  with  the  finger,  over  the  natural 
situation  of  the  anus,  which,  he  says,  invariably  causes  the 
child  to  strain,  or  make  efibrts  to  evacuate  its  bowels,  and 
thereby  produces  a  protrusion  of  this  part,  if  the  rectum  is 
distended  with  meconium,  which  will  be  conspicuous,  or  felt 
in  proportion  to  the  contiguity  of  the  intestine  to  the  external 
surface ;  unless  indeed  the  rectum  terminates  quite  high  up, 
then  there  will  be  no  protrusion  whatever,  and  no  fluctuation 
felt.    {Oj>.  cit,  p.  269.) 

In  some  of  the  cases  of  congenital  imperfection  of  the  anus 
and  the  rectum,  especially  in  the  peculiar  species  under  con- 
sideration, there  is  sometimes  found  a  small  excrescence  or 
elevation  of  the  skin  in  the  form  of  a  button,  or  of  a  crest,  as 
will  be  observed  in  several  of  the  cases  I  have  reported. 
These  excrescences,  from  their  peculiar  conformation,  might  at 


THE   THIRD   SPECIES   OF  MALFORMATIOX.  91 

first  sight,  be  regarded  by  a  superficial  observer  as  indicative 
of  an  anus,  and  also  lead  to  the  supposition  that  the  rectum 
would  be  found  in  their  immediate  vicinity ;  but  sucli  would 
not  be  the  case,  as  they  are  altogether  cutaneous  in  their 
structure,  and  liave  no  connection  or  communication  wliatever 
with  the  blind  end  of  the  rectum  which  in  these  instances  is 
generally  quite  remote  from  them. 

Sometimes  a  small  dejjression  or  a  pit,  or  a  fissure  or  fissures 
of  the  skin  exist  at  the  place  of  the  absent  anus.  Some  exam- 
ples of  this  kind  will  also  be  found  reported. 


SECTIOK     III. 

PROGNOSIS. 

It  has  been  a  source  of  much  regret  that  the  treatment 
heretofore,  of  those  cases,  in  which  there  is  an  absence  of 
from  one  and  a  half,  to  two  and  a  half  inches  of  the  inferior 
extremity  of  the  rectum,  has  not  been  crowned  with  more  suc- 
cess. "When,  however,  the  serious  and  sometimes  almost  des- 
perate character  of  such  cases  is  taken  into  consideration,  as 
well  as  the  many  difliculties  attending  the  old  and  imperfect 
methods  of  operating,  the  numerous  failures  heretofore,  have 
nothing  in  them  to  cause  surprise.  One  can  well  imagine  the 
gravity  of  such  an  operation,  and  how  difficult  a  thing  it 
would  be,  even  after  having  found  and  opened  the  end  of  the 
rectum,  to  establish  permanently  a  canal  in  so  soft  and  porous 
or  spongy  a  substance  as  the  peculiar  tissue  which  in  these 
cases  fills  the  wliole  space  which  the  intestine  itself  should 
naturally  occupy,  and  through  which  the  artificial  canal 
would  necessarily  have  to  pass,  and  how  very  inadequate 
such  tissue  would  be  as  a  substitute  for  the  muscular  rectum. 
The  dilficultieSj  therefore,  enumerated  by  Bell,  Yelpeau  and 


92  THE   THIRD    SPECIES    OF    MALFORMATION. 

others,  of  keejjing  such  a  canal  patulous,  are  by  no  means 
exaggerated  or  imaginary.  These  various  considerations  have 
induced  many  surgeons  to  look  upon  all  such  cases  as  entirely 
hopeless,  considering  the  operation  for  their  relief  to  be  too 
grave  and  uncertain,  and  more  hazardous  and  injurious  than 
beneficial — hence  they  repudiate  it  altogether.  Dr.  J.  H. 
Bigelow,  Professor  of  Surgery  in  the  Massachusetts  Medical 
College  of  Harvard  University,  says  that — "  Judging  from 
results,  I  do  not  consider  the  operation  for  imperforate  rec- 
tum, or  even  for  imperforate  anus,  a  desirable  one.  I  believe 
that  in  the  present  state  of  the  art,  it  is  better  that  a  child 
born  with  either  of  these  imperfections,  should  die  without  this 
operation  ;  although  it  must  occasionally  be  performed  in 
deference  to  established  opinion."  [Boston  Medical  and  Sur- 
gical Journal,  Vol.  Z VII., p.  24:0.     Boston:  1858.) 

I  am  surprised  that  so  able  a  surgeon  as  Dr.  Bigelow  should 
have  given  this  as  his  deliberate  judgment ;  that  such  doc- 
trine, so  directly  contrary  to  the  genius  of  this  age  of  real 
progress  should  have  emanated  from  so  high  a  source  as  the 
chair  of  surgery  in  the  Medical  Department  of  Old  Harvard 
University.  Should  the  sentiments  of  Dr.  Bigelow  be  strictly 
and  universally  adopted,  when,  I  ask  him,  would  the  "  present 

* 

state  of  the  art "  arrive  at  that  degree  of  j^erfection  which  would 
justify  the  operation  ?  Such  views,  if  carried  out  to  their  le- 
gitimate consequences,  would  for  ever  close  all  the  avenues  to 
future  improvement  in  the  art,  and  be  the  burial  ground  of 
all  further  progress.  Admit  for  the  sake  of  argument,  that 
the  operation  heretofore  has  utterly  failed  in  every  instance  ; 
what  then  ?  Are  we  on  this  account  to  abandon  all  such 
cases  to  their  fate,  in  future  ?  Are  we  to  sit  down,  fold  our 
hands,  quietly  look  on,  and  not  make  another  earnest  and  in- 
telligent effort  to  save  such  ?  Dr.  Bigelow,  however,  says 
that  this  operation  must  occasionally  be  performed  in  defer- 
ence to  established  oj>inion.  Can  it  be  possible  that  Dr.  Bige- 
low,   through    mere  regard    fjr  established   opinion  would, 


Till':    Tllliif)    SI'ECIKS    ()!•'    MAi;i'"OKMATIUN.  93 

imclor  any  circumstance,  perfonii  oi-  :i(l\is(,'  an  ()})cratiou  in 
which  he  had  no  conlidence  whatever,  and  wliich  he  believed 
woiikl  confer  nothing,  at  best,  but  a  lingering  miserable  deatli 
on  the  unfortunate  little  j^atient  ? 

I  admit  that  the  results  of  the  operation  heretofore,  have,  in 
a  majority  of  instances  been  unfortunate,  but  a  much  lai-ger 
number  of  cases  have  been  saved  by  it,  than  is  generally  sup- 
posed ;  and  many  of  the  fears  of  surgeons  with  regard  to  it, 
are  ill  founded  and  greatly  exaggerated,  as  well  as  are  their 
denunciations  of  it,  unjust.  Notwithstanding  this  proscription 
of  the  operation  by  several  eminent  surgeons,  it  is  nevertheless 
sufficiently  justified,  even  admitting  the  uncertainty  and  the 
danger  attending  it,  by  the  success  of  a  number  of  cases  of  a 
most  desperate  character,  which  wdll  be  found  recorded  in 
full  in  this  chapter.  The  highly  encouraging  results  in  these 
cases,  authorise  and  warrant  an  attempt  at  relief  by  some  op- 
eration. An  operation  may  not  be  followed  by  the  desired  re- 
sult, still  an  attempt  should  be  made,  unless  there  should  be 
other  complications  or  conditions  of  the  system  that  would 
contra-indicate  it.  A  very  favorable  issue,  however,  of  the 
success  of  the  operation  in  any  of  these  cases  must  not  be  too 
confidently  prognosticated. 

Some  surgeons  denounce  the  operation  as  being  a  cruel,  a 
most  barbarous  proceeding,  and  on  this  account  decline  alto- 
gether to  perform  it.  I  would  most  respectfully  refer  all  such 
to  the  reports  of  several  cases  given  in  this  chapter,  in  which 
the  little  dying  patients  were  so  astonishingly  relieved  by  the 
operation,  that  they  immediately  after  nursed  vigorously,  slept 
most  tranquilly,  and  ultimately  recovered. 

The  disrepute  into  which  the  treatment  of  such  cases  hereto- 
fore has  fallen,  may  be  in  a  great  measure  justly  attributable 
to  ignorance  of  the  anatomical  and  pathological  conditions 
and  relations  that  pertain  to  these  cases  ;  to  the  w^ant  of  skill 
in  the  operator  ;  to  an  imperfect  method  of  operation  ;  to  the 
operation  being  contra-indicated,  &c. 


94  THE   TriTKD    SPECIES    OF   MALFOR:\IATIO^*. 

Tlie  treatment  laid  down  and  recommended  in  tliis  chapter, 
if  perse veringly  carried  out  witli  judgment,  caution  and  tact, 
will,  in  my  opinion,  in  the  majority  of  cases,  if  not  in  all,  not 
only  preserve  the  life  of  the  child,  but  also  j)revent  those  sad 
consequences  which  so  often  unfortunately  attended  the  treat- 
ment heretofore  pursued. 

The  celebrated  French  surgeons,  MM.  Amussat.  Eoux  de 
Brignoles  and  Goyraud,  in  their  various  publications  on  this 
subject,  during  the  years  1834  and  1835,  declared  that  pre- 
vious to  that  time,  such  cases  as  we  are  now  considering,  were 
never  successfully  treated,  if  treated  at  all,  but  were  suflPered 
to  perish,  because,  as  they  imagined,  their  predecessors  had 
not  sufficient  skill  and  courage  to  make  free  incisions  in  the 
perinasum,  in  order  to  search  for,  and  to  find  the  blind  end  of 
the  rectum,  when  it  laid  deep.  Tliey  claimed  great  merit  to 
themselves  for  introducing  as  something  entirely  new  in  such 
cases,  free  incisions  with  a  scalpel  guided  by  the  finger,  instead 
of  the  old  method  of  punctures  with  the  lancet  or  the  trocar. 

Although  these  gentlemen  deserved  great  credit  for  calling 
public  attention  to  this  entirely  neglected,  but  most  important 
subject,  at  that  time,  and  for  introducing  several  valuable  im- 
provements in  the  mode  of  operating,  they  nevertheless  were 
egregiously  mistaken  in  supposing  that  no  bad  cases  of  this 
kind  were  ever  previously  treated  with  success,  and  that 
they  had  the  honor  of  first  suggesting  and  putting  into  prac- 
tice the  method  by  dissection  with  a  scalpel  guided  by  the 
finger.  The  evidence  that  will  be  adduced  in  this  chapter 
will  place  this  matter  beyond  all  controversy.  It  will  estab- 
lish the  fact  that  such  cases,  even  of  the  most  desperate  char- 
acter, Avere  sometimes  successfully  treated  both  by  dissection 
as  well  as  by  puncture,  for  years  previous  to  the  promulgation 
of  the  views  of  these  gentlemen,  and  that  they  were  by  no 
means  the  originators  of  the  method  by  dissection. 

Benjamin  Bell  more  than  half  a  century  previous,  not  only 
taught,  but  successfully  performed  dissection  in    just    such 


THE    THIRD    SPECIES    OF   MALFORMATK  i.V.  95 

cases.  His  directions  for  the  performance  of  this  operation, 
I  will  give  in  his  own  language. — "  In  such  cases,"  says  lie, 
"  when  the  gut  is  found  to  lie  deep,  on  the  child  heiug  ])roperly 
secured,  an  incision  of  an  inch  in  length  should  Itc  made  di- 
rectly on  the  spot  where  the  anus  ought  to  be ;  and  this 
should  be  continued  by  gradual  and  repeated  strokes  of  the 
scalpel,  in  the  direction  the  rectum  is  usually  known  to  take ; 
not  in  a  direct  course  through  the  axis  of  the  pelvis  ;  for  in 
that  direction  the  vagina  or  bladder  or  perhaps  both  might  be 
brought  to  sufter;  but  backwards  and  along  the  coccyx, 
wdiere  there  is  no  risk  of  w^ounding  any  part  of  importance. 
The  best  director  in  every  case  of  this  kind,  is  the  finger  of 
the  operator.  The  fore  finger  of  one  hand  being  pushed  in 
towards  the  coccyx,  the  surgeon  with  the  scalpel  in  the  other, 
should  dissect  gradually  in  this  direction,  either  till  he  meets 
with  fffices,  or  till  the  scalpel  has  reached  at  least  the  full 
length  of  his  finger ;  and  if  after  all  the  feeces  are  not '  evacu- 
ated, as  death  must  undoubtedly  ensue  if  something  further 
be  not  attempted,  a  long  trocar  should  be  pushed  forward 
upon  the  finger  in  such  a  direction  as  the  operator  thinks  will 
most  probably  meet  with  the  gut." — (^1  System  of  Surgery. 
Vol.  II.  Ckaj).  XIX.  I).  Ta.     Edlnhurgh:  1787.) 

These  were  the  graphic  instructions  of  Mr.  Bell,  and  he 
'himself  put  them  into  successful  execution  in  two  formidable 
cases.  [  Vide  Cases  XXX. — XXXI^ 

Tliis  operation  too  was  successfully  performed  in  the  year 
1822,  by  the  late  and  distinguished  Mr.  A.  Copeland  Hutchi- 
son, of  England,  whom  I  have  already  favorably  noticed. 
The  case  upon  wdiicli  he  operated  w^as  one  among  the  worst 
on  record,  and  the  operation  did  not  difter  essentially  from 
that  recommended  by  Mr.  Bell.  I  have  reported  the  case  in 
full.  ■[  Vide  Case  XXXVI.^ 

A  formidable  case  was  successfully  treated  in  the  year  1800, 
now  sixty  years  ago,  in  our  own  country,  and  in  the  then 
wilds  of  my  owai  adopted  State — ^Iventucky.     I  feel  proud  to 


96  THE   THIRD    SPECIES    OF    MALFORMATION. 

inform  those  distinguislied  French  snrgeons,  that  even  at  that 
distant  day,  and  in  the  wild  woods  of  Kentucky,  a  surgeon 
was  found  who  possessed  both  the  ability  and  the  courage  to 
execute  successfully  such  a  difficult  and  dangerous  operation. 
Tluxt  surgeon  was  Dr.  John  P.  Campbell,  of  Flemingsburg, 
Kentucky.  Tliis  case  of  Dr.  Campbell  will  be  found  reported 
in  full.  [  Vide  Case  XXXV.] 


SECTIOI^^     IV. 

THE  TREATMENT. 

The  treatment  which  holds  out  the  greatest  prospect  of  suc- 
cess in  these  cases,  is  that  which  contemplates  the  establish- 
ment of  an  artificial  anus  in  the  perinseum — Proctoplasty. 
By  this  operation  the  cul-de-sac  of  the  rectum  is  sought  for, 
through  a  passage  made  for  this  purpose  by  dissecting  through 
the  tissues  which  separate  it  from  the  cutaneous  surface ;  and 
when  found  of  breaking  up  its  adhesions,  if  any,  seizing  it 
with  forceps,  bringing  it  down,  opening  it,  emptying  its  con- 
tents, and  uniting  its  cut  edges  to  those  of  the  perinatal 
wound  in  the  natural  situation  of  the  anus,  according  to  the 
method  of  M.  Amussat.  If  the  blind  sac  of  the  rectum,  how- 
ever, cannot  be  brought  down  without  undue  force,  in  conse- 
quence of  the  organ  being  too  short,  or  its  adhesions  being 
too  numerous  and  strong,  it  must  be  opened  where  it  is,  by  a 
cnicial  incision,  and  the  passage  which  has  been  made  to  it, 
must  be  kept  open  and  supply  and  perform  the  functions  of 
that  portion  of  the  rectum  which  is  wanting,  according  to  the 
ordinary  method. 

1.  When  should  the  Operationhe  Undertaken?  Mr.  A.  Cope- 
land  Hutchison  advises  in  obscure  cases  of  this  character — 
that  is,  in  cases  in  which  it  is  very  difficult  to  determine  from 


Till';    THIRD  SPKCIKS    OK   MALFORMATION.  97 

present  indications  where  the  blind  sue  uf  the  rectum  is,  or 
whether  this  organ  exists  at  all  or  not — to  postpone  the  opera- 
tion, if  possible,  for  twenty-four,  or  sixty  hours  after  hirth,  as 
no  inconvenience  will  generally  arise  from  the  delay  ;  the  dis- 
tention of  the  rectum  by  the  meconium  and  fjiecal  matter  will 
be  in  the  mean  time,  a  most  invaluable  guide  to  the  surgeon 
in  making  his  incisions,  and  in  searching  for  the  cul-de-sac  of 
the  rectum.    {Op,  clt.  p.  257.) 

Professor  Dicffenbach  recommends  the  operation  to  be  per 
formed  on  the  second  day  after  the  birth  of  the  child,  for  the 
same  reasons.  {Die  Operative  Cldrurgie.  Band  1.  S.  672. 
Leipzig:  1845.) 

Although  the  delay  advised  by  these  authors  is  of  much 
importance  in  facilitating  the  operation,  and  the  search  for  the 
rectum,  yet  it  is  very  liable  to  be  abused,  by  being  carried 
too  far,  for  it  is  by  no  means  as  void  of  danger  as  they 
imagine.  The  primary  object  in  such  cases  is  to  empty  as 
soon  as  possible  the  distended  intestines — lest  they  become 
inflamed,  paralysed  or  lacerated,  and  thus  jeopard  the  life  of 
the  child.  When  the  operation  has  been  delayed  too  long, 
the  difficulty  after  its  performance  often  is,  that  the  bowels 
will  not  act  at  all,  having  completely  lost  their  peristaltic  ac- 
tion by  having  remained  too  long  loaded  and  stretched  with 
meconium  and  gas,  and  the  child  generally  dies  in  a  day  or 
tw^o.  I  am  of  the  opinion  that  the  operation  should  be  per- 
formed as  soon  as  the  child  manifests  its  sufferings,  by  its 
cries  or  moans,  and  the  agitation  of  its  limbs,  or  its  general 
restlessness ;  or  at  least  it  ought  not  to  be  postponed  longer 
than  when  free  vomiting  has  taken  place,  because  then  the 
distention  of  the  rectum  by  the  meconium  and  the  gas,  which 
is  so  important  in  the  search  for  the  blind  end  of  that  organ, 
is  sufficient  for  the  purpose. 

The  practice  of  administering  purgatives  for  the  purpose  of 
forcing  down  the  rectum,  preparatory  to  the  operation,  cannot 

be  too  strongly  reprobated. 

7 


98 


THE   THIKD  SPECIES    OF   MALFOKMAIIOJT. 


2.  The  Infant  Pelvis.  Some  idea  may  be  formed  of  the 
average  dimensions  of  the  infant  pelvis  in  the  normal  state,  by 
the' following  admeasurements  I  made  of  it  in  two  new-born, 
well-developed  male  infants,  at  full  time  : 

From  one  tuberosity  of  the  ischium  to  the  other — 
one  inch  and  one  line. 

From  the  os  coccygis  to  the  symphysis  pubis — one 
inch  and  three  lines. 

From  the  os  coccygis  to  the  jDromontory  of  the 
sacrum — one  inch  and  two  lines. 

From  one  tuberosity  of  the  ischium  to  the  other — 
one  inch. 

From  the  os  coccygis  to  the  symjDhysis  pubis — one 
inch  and  one  and  a  half  lines. 

From  the  os  coccygis  to  the  promontory  of  the 
sacrum — one  inch  and  one  line. 


In  the  instances  in  which  the  rectum  is  either  partially  or 
wholly  absent,  the  pelvis  is  generally  of  smaller  capacity  than 
when  normal,  having  also  undergone  to  some  extent  an  arrest 
of  development,  and  being  deformed  to  a  greater  or  less 
degree.  The  tuberosities  of  the  ischium  approach  nearer  each 
other,  in  consecpience  of  the  narrowness  of  the  pelvic  cavity 
common  in  these  cases. 

Deej)  incisions  into  the  infant  pelvis,  are,  as  a  matter  of 
course,  always  attended  with  more  or  less  difficulty  and  dan- 
ger. This  of  necessity  must  be  so  in  such  cases,  on  account 
of  the  small  size  of  tlie  pelvis  as  a  theatre  for  such  an  opera- 
tion, especially  when  we  take  into  consideration  the  presence 
of  the  important  viscera  which  still  further  lessens  its  diame- 
ters, and  the  close  proximity  of  the  iliac  and  hypogastric 
arteries  and  veins  which  endanger  the  dissection  in  the  search 
for  the  rectum. 


THE   THIUD   SPECIES   OF   MALFORMATION.  99 

3.  Introchtdioih  of  the  Sound.  Soinc  surgeons,  previous  to 
performing  the  o^Jcration,  recommend  the  introduction  of  a 
small  silver  sound  or  catheter  into  the  bladder  of  the  male, 
and  a  large  metallic  sound  slightly  curved,  into  the  vagina  of 
the  female,  to  determine  the  direction  and  the  position 
of  tliese  organs,  in  order  to  guard  against  wounding  them. 
TJie  first  proceeding  is  difKcult  and  sometimes  imj^ossible  to 
accomplish,  and  neither  of  them,  in  my  opinion,  absolutely 
necessary,  provided  the  oi^cration  is  cautiously  conducted.  1 
admit  that  the  sound  might  considerably  facilitate  the  searcli 
for  the  rectum  along  the  anterior  wall  of  the  pelvis,  whicli 
sometimes  becomes  necessary  when  the  organ  occupies  an  ab- 
normal position. 

4.  The  Form  of  Incision.  In  the  operation  for  perineal  arti- 
ficial anus,  surgeons  have  severally  recommended  the  longitu- 
dinal.^ the  transverse,  the  crucial,  and  the  T  incision. 

The  longitudinal  incision  should,  in  my  opinion,  have  the 
preference,  because  by  it  a  larger  wound  may  be  obtained 
without  danger,  which  sometimes  becomes  necessary  in'  mak- 
ing a  thorough  and  extensive  search  for  the  rectal  extremitv. 
This  incision,  if  necessary,  can  be  extended  from  the  posterior 
margin  of  the  scrotum,  or  from  the  posterior  commissure  of 
the  labia  majora,  to  the  extremity  of  the  coccyx.  Another 
very  important  consideration  is  that  by  it,  the  cicatricial  tis- 
sue which  results  from  wounds  in  the  vicinity  of  the  anus  is 
much  less  extensive  than  in  any  of  the  other  incisions,  and 
consequently  greatly  diminishes  the  risk  of  contraction  after 
the  operation. 

The  transverse  incision  has  no  advantage  whatever  over  the 
longitudinal,  and  should  it  be  carried  to  the  necessary  extent, 
it  might  approach  too  near  to  the  tuberosity  of  the  ischium, 
and  run  the  risk  of  wounding  the  internal  pudic  artery,  and 
seriously  injure  also  the  sphincter  ani  muscles,  as  the  pelvic 
cavity  in  these  cases,  is  generally  narrower,  and  the  tuberosi- 
ties of  the  ischium  much  nearer  each  other  than  natural. 


100  THE   THIED   SPECIES   OF   MALFORMATION. 

Tlie  crucial  and  the  T  incision  are  botli  objectionable 
on  account  of  favoring  the  contraction  of  the  anus  by  the 
formation  of  a  greater  extent  of  cicatricial  tissue. 

Great  care  should  be  taken,  that  whatever  incision  is 
adopted,  that  it  be  healed  by  the  first  intention,  as  sup- 
puration always  results  in  an  increased  extent  of  cicatricial 
tissue,  and  thus  favors  a  greater  contraction  of  the  newly- 
formed  anus. 

5.  The  Sphinctores  Ani  Muscles.  M.  Eoux  de  Brignoles 
advises  that'  the  perinseal  artificial  anus  should  always  be 
established  exactly  in  the  mesial  line  of  the  sphincter  ani  mus- 
cles, and  that  in  conducting  the  dissection,  the  fibres  of  these 
muscles  should  be  most  carefully  separated,  and  their  internal 
margin  loosed,  so  as  to  preserve  their  freedom  of  action,  and 
secure,  what  is  of  the  greatest  importance,  their  utility  in  the 
act  of  defecation.  {Archives  Generales  de  Medicine.  2d  Ser. 
tome  V.  p.  475.) 

Tliis  advice  of  M.  Roux  is  highly  important  and  judicious, 
and  should,  as  far  as  practicable,  be  always  followed,  in  all 
the  cases  in  which  those  muscles  do  really  exist.  The  task, 
however,  of  distinguishing  and  separating  these  muscular 
fibres,  is  by  no  means  so  easy  to  accomplish,  as  one  would 
suppose  from  reading  the  remarks  of  M.  Koux. 

M.  Yelpeau  says  that  this  method  of  Eoux  has  no  superior- 
ity over  the  ordinary  one  ;  but  this  is  a  loose  assertion  of  his, 
and  does  not  merit  much  attention. 

Upon  the  subject  of  the  invariable  presence  or  absence  of 
the  sphinctores  ani  muscles  in  these  particular  cases  of  con- 
genital malformation,  there  is  a  singular  diversity  of  opinion 
existing  among  authors. 

M.  Eoux  de  Brignoles  maintains  that  these  muscles  which 
receive  their  nutrient  arteries  from  the  ischiatic,  are  never 
wanting,  that  they  exist  independently  of  the  rectum — ^lience 
his  advice  so  to  conduct  the  dissection,  as  to  preserve  them  in 


TIIK   Tllllil)    SPECIES   OF   MALFORMATION.  101 

connection  with  the  iirtiticiul  unus,  luul  thus  euul)le  the  patient 
to  have  control  over  the  retention  of  the  fajces.  {Memoire  de 
VAcacUmie  Iloyale  de  Medicine,  tome  1 V.  />.  183.  Paris : 
1835.) 

M.  Bhindin,  on  tlie  contrary  however,  asserts  that  when 
the  anns  is  completely  absent,  he  has  ascertained  that  tlie 
sphincter  muscle  is  invariably  absent  also  ;  this  being  always 
the  case  whether  the  skin  does,  or  does  not  present  an  indica- 
tion of  the  natural  situation  of  the  anns — hence  he  advises  that 
the  artificial  anus  should  be  formed  in  the  abdomen,  because 
an  artificial  anus  in  the  perinseuin,  destitute  of  a  sphincter 
muscle,  would  occasion  incontinence  of  fseces  to  a  greater  ex- 
tent, and  be  attended  witli  more  inconvenience  and  discom- 
fort, than  one  established  in  the  abdomen.  {Dictionnaire  de 
Medicine  et  de  Chirurgie  Pratiques.     Paris  :  1832.) 

Tiingel,  a  late  and  very  able  German  writer  on  abdominal 
artificial  anus,  considers  the  absence  of  the  sphinctores  and 
levatores  ani  muscles  as  a  rule  in  congenital  imperforation  of 
the  anus  and  the  rectum ;  and  uses  this  as  a  strong  argument 
against  a  perinoeal  artificial  anns,  and  in  favor  of  an  abdomi- 
nal one.  ( Uher  KunstlicJie  Aflerbildung.  S.  203.  Kid  : 
1853.) 

M.  Yelpeau  is  also  of  opinion  that  the  sphincter  muscle  in 
all  such  cases  is  always  absent.  {OpeTati've  Surgery.  Vol. 
HI.  p.  1090.     Motfs  English  Versioii.     New  York :  1847.) 

M.  Goyraud  mentions  it  as  an  undeviating  rule  that  the 
superior  portion  of  the  sphincter  ani  is  always  absent  when 
the  inferior  portion  of  the  rectum  is  deficient ;  but  that  the 
inferior  portion  of  this  muscle,  not  only  always  exists,  but  is 
preternaturally  developed  in  these  cases — ^hence  he  comes  to 
the  same  practical  conclusions  that  M.  Koux  does.  {Journal 
Ileldornadaire  des  Progress  des  Sciences  et  Institutions  Medi- 
cales.  tome  III.  p.  245.     Paris :  1834.) 

M.  Petit  observes  that  in  all  such  cases  of  imperforate  anus, 
the  sphincter  ani  muscle  indeed  exists,  but  it  is  so  contracted, 


102  THE   THIKD    SPECIES   OF   MALFOEMATION. 

■wasted,  and  confounded  with  the  surrounding  parts,  that  it  is 
difficult,  or  rather  impossible  for  it  to  resume  its  function, 
with  whatever  care  the  operation  may  be  performed.  (Re- 
marques  sur  les  differens  vices  de  conformations  que  les 
enfans  apportent  en  naissant.  Mcmoire  de  V AcademieRoyale 
de  Cliirurgie.  tome  II.     Paris:  1781.) 

Mr.  A.  Copeland  Hutchison  mentions  a  case  in  which  the 
sphinctores  ani  were  wanting,  but  the  levatores  ani  were  per- 
fect and  strong.    {Op.  cit.  p.  271.) 

The  only  just  and  practical  conclusions  to  be  drawn  from 
these  conflicting  opinions,  are  that,  in  some  of  these  cases,  the 
sphinctores  ani  muscles  exist,  whilst  in  others  they  do  not ; 
but  whether  they  are  present  or  absent,  the  artificial  anus 
should  always,  if  possible,  be  established  in  the  natural  situa- 
tion in  the  perinseum,  for  should  these  muscles  be  absent,  the 
infirmity  is  greatly  less,  even  in  this  depending  situation,  than 
Blandin  and  Tiingel  declare.  Should  these  muscles,  however, 
be  present,  the  operation  should  be  so  especially  conducted, 
as  by  all  means  to  preserve  their  functions  to  the  newly- 
formed  anus  as  recommended  by  M.  Eoux. 

I  have  elsewhere  presented  in  full  a  highly  interesting  case 
successfully  operated  on  by  M.  Roux.  This  case  will  com- 
pletely illustrate  his  peculiar  and  admirable  method  of  ope- 
rating.   \_Vide  Case  CLXYIIi\ 

6.  Abnormal  Position  of  the  Rectum.  If  the  cul-de-sac  of 
the  rectum  should  not  be  found  through  the  incision  made  \(^ 
the  full  extent  in  the  normal  direction  and  position  of  this  in- 
testine, it  is  still  no  positive  evidence  that  it  does  not  exist,  for 
as  I  have  elsewhere  already  observed,  that  besides  being 
abnormal,  the  rectum  may  sometimes  occupy  an  abnormal 
position  in  the  pelvic  cavity — hence  the  important  necessity 
of  varying  more  or  less  the  search  for  it  before  abandoning 
the  case ;  for  continuing  the  search  in  the  same  direction 
would  not   only   result   in   a  failure   to   find   it,   but    also, 


THK   THIRD    SPECIKS    OF    MALFOUMA.TION.  Hl3 

in  tlie  loss  of  the  patient.  Instances  have  occuiTcd  in  ■\vliicli 
the  surgeon,  after  searching  for  the  rectum  in  tlie  natural 
direction  and  position  of  tliis  organ,  failed  to  find  it  there, 
and  abandoned  the  case  ;  afterwards  at  the  auto})sy  he  dis- 
covered it  in  another  jjosition  in  the  pelvic  cavity,  from 
which  he  might  easily  have  drawn  it  into  the  incision  he  had 
made  in  the  perinaeum,  without  any  difficulty  or  danger, 
if  during  the  operation  this  abnormal  position  of  the  rec- 
tum had  been  known  or  thought  of.  [  Vide  Plate  XI V.  ] 

A  number  of  cases  will  be  found  reported  in  this  work,  in 
which  the  discovery  was  made  at  the  autopsy,  that  if  the 
search  for  the  end  of  the  rectum  had  been  varied  even  in  a 
slight  degree  from  the  natural  direction  of  this  intestine,  it 
would  have  been  found,  and  the  patient,  in  all  probability, 
saved.  Or  if  the  point  of  the  bistoury  or  trocar,  in  the  opera- 
tion of  puncture,  had  been  slightly  changed  in  its  direction, 
the  end  of  the  rectum  would  have  been  penetrated. 

It  is  scarcely  necessary  to  observe  that  during  the  oj^eration, 
the  blood,  from  time  to  time,  should  be  well  sponged  out  of 
the  wound,  the  haemorrhage,  however,  is  generally  but  slight 
if  proper  care  is  taken ;  and  that  the  dissection  should  be  con- 
ducted with  as  much  dispatch  as  would  be  compatible  with 
the  safety  of  the  child.  Infants,  however,  are  found,  as  I  have 
elsewhere  observed,  to  bear  a  great  deal  without  any  bad  re- 
sults, provided  no  imj)ortant  vessel  or  structure  is  injured. 

Y.  The  Method  of  Operating.  When  the  operation  is  deter- 
mined on,  the  little  patient  should  be  placed  on  its  back  on  a 
table,  or  on  the  lap  of  an  assistant,  as  in  the  lateral  operation 
for  lithotomy,  its  legs  should  be  flexed  and  held  apart  by  two 
assistants,  and  the  nates  completely  exposed  and  inclined  for- 
ward. If  the  catheter  or  the  sound  is  decided  on  being  used, 
it  must  now  be  introduced  and  held  by  an  assistant.  The 
surgeon  placing  himself  in  front,  should  with  the  thumb  and 
index  finger  of  the  left  hand,  stretch  the  integuments  of  the 


104  THE    THIRD    SPECIES    OF    MALFORMATION. 

perineum,  and  with  the  round-bellied  scalpel  in  his  right, 
make  a  longitudinal  incision  on  the  median  line  through  the 
skin,  commencing  with  the  posterior  margin  of  the  scrotum, 
or  at  the  posterior  j^oint  of  the  commissure  of  the  labia  majora, 
and  extending  to  the  termination  of  the  coccyx,  unless  he 
should  think  that  a  shorter  incision  would  give  him  ample 
room.  The  lips  of  the  wound  now  being  drawn  apart,  the 
operator  should  dee23en  the  incision  in  the  natural  direction  of 
the  rectum,  by  cautiously  incising  little  by  little  the  different 
layers  of  the  perinseum  in  succession  as  they  present  them- 
selves, exploring  well  with  the  index  finger  of  the  left  hand 
before  each  stroke  of  the  scalpel,  to  ascertain  the  position  of 
the  bladder  or  the  vagina,  so  as*  not  to  wound  it,  and  also  to 
recognize  by  the  projection  and  the  fluctuation,  the  blind  sac 
of  the  rectum.  Tlie  finger  is  better  than  either  the  probe  or 
the  sound  for  this  purpose,  and  it  also  serves  to  guide  the 
knife,  being  the  best,  if  not  only  director,  that  should  be  used 
in  such  cases.  Extreme  care  should  also  be  taken  to  avoid 
the  great  pelvic  vessels  at  the  sides,  and  the  sacrum  behind, 
lest  as  it  regards  the  latter,  the  knife  should  get  behind  the 
rectum,  of  which  it  is  in  search,  and  miss  it  altogether,  or 
wound  it  some  distance  above  its  cul-de-sac.  After  the  opera- 
tor has  penetrated  as  far  as  the  pelvic  aponeurosis  without 
meeting  the  end  of  the  rectum,  he  should  then  divide  this  tis- 
sue also,  and  search  for  it  in  the  pelvic  cavity.  The  edges  of 
the  wound  may  be  kept  asunder  by  crotchet  hooks,  so  that  the 
cavity  may  be  explored  both  by  touch  and  by  sight.  The 
finger  can  be  introduced  from  two,  to  two  and  a  half  inches  in 
depth,  towards  the  promontory  of  the  sacrum,  so  that  the  end 
of  the  rectum  may  be  reached,  if  the  organ  is  not  enfirely 
wanting,  or  if  it  is  not  interrupted  in  its  superior  portion  and 
adhering  to  the  superior  wall  of  the  bladder.  If  in  searching 
towards  the  promontory,  of  the  sacrum,  the  rectum  cannot  be 
found,  the  operator  should  not  fail  to  explore  the  anterior  wall 
of  the  pelvis.     To  this  end,  the  perinatal  wound,  if  necessarv, 


TIIH   TIIIKD    SPECIES    OF   MALFOUMATION.  105 

may  be  eiihir^xMl,  in  order  to  examine  whether  the  tciiiiinul 
end  of  til e  rectnni  may  not  be  adhering  to  the  bladder,  to  llie 
vagina,  or  to  the  uterns. 

Should  the  operator  at  any  time  during  the  search  detect 
with  his  finger  a  Huctuating  tumor,  more  or  less  elastic,  and 
of  a  dark-br(nvn  color,  which  he  can  ascertain  if  necessary  by 
the  speculum  ani,  he  may  be  assured  that  it  is  the  rectum ; 
and  when  thoroughly  convinced  of  this,  he  should  seize  the 
projecting  end  of  it  with  the  bull-dog  forceps,  or  double 
tenaculum,  and  endeavor  to  draw  it  gently  downwards  into 
the  perinteal  wound ;  no  very  considerable  force,  however, 
must  be  applied,  and  if  it  does  not  yield,  it  wdll  be  owing  to 
adhesions  which,  if  not  too  numerous  and  too  strong,  should 
be  carefully  loosened  by  the  fingers,  if  possible,  using  the 
knife  or  scissors  only  when  they  are  very  firm,  and  rec^uire 
great  care  in  their  division.  It  is  important  and  always  very 
desirable  that  the  projecting  and  terminal  end  of  the  rectum 
should  be  brought  down  into  the  perin^eal  wound,  but  if  this 
is  impossible,  in  consequence  of  its  locality  and  adhesions,  the 
operator  should  not  hesitate  to  seize  any  easy  movable  portion 
of  the  rectum  which  may  be  near,  and  bring  it  down  into  the 
external  w^^und,  to  serve  in  the  formation  of  the  anus.  The 
terminal  end  of  the  rectum  being  left  in  its  position,  and  being 
cut  off  from  the  circulation  of  the  f^cal  matter,  will  gradually 
contract,  and  ultimately  become  obliterated. 

As  soon  as  the  end  of  the  rectum  is  brought  down  suffi- 
ciently low,  a  needle  armed  with  a  double  ligature  should  be 
passed  through  it,  by  means  of  which,  and  the  forceps  or 
hooks,  it  should  be  drawn  down  to  the  level  of  the  integu- 
ments. The  cul-de-sac  should  now  be  opened  by  a  longitudi- 
nal incision  from  front  to  rear,  its  contents  conq^letely  emp- 
tied, the  wound  thoroughly  cleansed,  and  its  cut  edges 
attached  by  six  points  of  suture  to  the  integument  of  the 
corresponding  edges  of  the  perinssal  wound,  in  the  exact  and 
proper  situation  of  the  anus,  care  being  taken  that  the  mucous 


106  THE   THIKD    SPECIES    OF   ilALFOEMATION. 

membrane  should  overlap  the  external  skin,  in  order  to  pre- 
vent the  stercoral  matters  from  escaping  into  the  cellular  tis- 
sue between  them.  The  remainder  of  the  perinseal  wound, 
both  in  front  and  behind  the  newly-formed  anus,  should  then 
be  closed  by  suture.  The  child's  legs  should  be  bound 
together  by  a  bandage,  the  wound  dressed  with  a  compress 
dipped  in  a  cooling  lotion,  and  frequently  renewed,  over 
which  the  usual  napkin  should  be  applied  to  receive  the  dis- 
charges, and  the  child  placed  by  the  side  of  its  mother  in  bed 
and  kept  warm. 

After  the  operation,  it  is  indispensable  to  success  that 
extreme  care  should  be  taken  of  the  child.  If  the  mother 
cannot  nurse  it,  choice  must  be  made  of  a  good  wet-nurse. 
Full  baths  and  frequent  emollient  injections  should  be  en- 
joined, and  an  equable  temperature  should  be  maintained  in 
the  apartment.  The  artificial  opening,  which  always  tends  to 
contract,  should  also  be  closely  watched,  and  sufficiently 
dilated,  from  time  to  time  by  the  finger  or  elastic  bougies. 

8.  Tlie  Ordinary  Method  of  Operating.  By  this  method  the 
end  of  the  rectum  is  sought  for,  much  in  the  same  manner  as 
by  the  preceding,  but  instead  of  being  brought  down  when 
found,  it  is  opened  and  suffered  to  remain  in  the  exact  posi- 
tion in  w^hich  it  was  discovered,  and  the  passage  which  has 
been  made  up  to  it  through  the  perinseum,  must  be  kept  open 
and  supply  that  portion  of  the  rectum  which  is  absent.  The 
difficulty  and  the  success  of  this  proceeding  depend  in  a  great 
measure  upon  the  higher  or  the  lower  position  of  the  blind  sac 
of  the  rectum,  for  in  proportion  to  the  distance  of  the  cul-de- 
sac  from  the  skin  of  the  perineum,  will  be  the  danger  of  faecal 
infiltration,  and  the  difficulty  of  maintaining  a  sufficiently  free 
and  permanent  opening  after  the  operation. 

If  the  surgeon,  after  having  found  the  cul-de-sac  of  the  rec- 
tum, should  find  it  impossible  to  bring  it  down  into  the 
perinseal  wound  as  already  advised,  in  consequence  of  its 


TIIK   THIRD    SPECIES   OF   aiALFORMATION.  107 

peculiar  position,  its  numerous  and  strong  adiiesions,  or  its 
shortness,  lie  slioukl  have  recourse  to  the  ordinary  method. 

As  soon  as  the  rectum  is  discovered  by  the  surgeon,  its  pro- 
jecting point  should  be  well  exposed,  and  the  sharp-pointed 
bistoury,  or  a  trocar,  thrust  into  it,  and  the  contents  of  the 
bowel  evacuated,  especial  care  being  taken  to  make  the  punc- 
ture directly  in  the  end,  if  possible,  and  not  in  the  side  of  the 
rectum.  The  puncture  thus  made  should  then  be  enlarged 
crucially,  with  the  probe-pointed  bistoury  guided  by  the  lin- 
ger, taking  care  to  make  it  sufficiently  free  and  permanent  at 
first,  in  order  to  avoid  a  second  effort,  as  the  tendency  to  con- 
traction is  always  much  greater  in  subsequent  operations. 
When  the  blind  end  of  the  rectum  is  thick,  hard  or  knotty, 
resembling  cicatricial  tissue,  as  is  sometimes  the  case,  the 
whole  of  it,  or  as  much  of  it  as  possible,  should  be  removed, 
provided  it  can  be  done  safely.  After  the  opening  has  been 
sufficiently  enlarged  and  the  rectum  completely  emptied  and 
washed  out  by  warm  mucilaginous  enemata,  that  part  of  the 
perinseal  wound,  in  front  and  rear  of  the  portion  designed  for 
the  anus,  should  now  be  closed  by  suture,  taking  care,  how- 
ever, to  leave  a  sufficiently  ample  opening,  and  in  the  proper 
place,  for  the  new  anus.  A  silver  canula  much  in  the  form 
of  a  nipple,  or  similar  to  the  tracheotomy  tube,  with  a  very 
slight  curvature  adapted  to  the  direction  of  the  rectum,  the 
length  of  the  newly-made  passage,  and  about  three-eighths  of 
an  inch  in  diameter,  should  now  be  introduced  and  secured  in 
its  situation  by  two  strips  of  tape  passed  through  rings  at  the 
external  end  of  the  canula,  and  tied  in  front  and  behind  to  a 
circular  bandage  fastened  round  the  body.  The  usual  napkin 
and  a  compress  dipped  in  a  cooling  lotion,  should  now  be 
applied,  and  the  child  put  to  bed. 

It  would  be  advisable  to  have  several  of  these  tubes  of  dif- 
ferent sizes  on  hand,  in  order  that  while  one  was  out  and 
being  cleansed,  the  other  might  be  in.  They  should  be  con- 
structed with  their  superior  extremity  bevelled  or  rounded 


108  THE   TUIKD    SPECIES    OF   MALFOKMATION. 

off,  to  facilitate  tlieir  introduction,  and  their  inferior  extremity 
should  be  furnished  with  a  shoulder,  anteriorly  and  poste- 
riorly, with  a  ring  in  each  to  put  the  tape  through,  for  the 
purpose  of  confining  them  in  their  situation.     [  Vide  Plate 

11,  Figure  12.]  The  silver  tubes  are  the  best ;  elastic 
ones,  however,  if  lined  with  flexible  metal,  are  very  good 
and  answer  very  well. 

Tlie  canula  should  be  frequently  withdrawn  and  cleansed 
and  the  newly-made  passage  washed  out,  and  should  there 
exist  any  undue  irritation,  the  parts  should  be  often  well 
bathed  or  fomented  to  allay  it.  The  tube  shields  the  raw  and 
highly  delicate  surface  of  the  newly-made  canal  from  the  irri- 
tating effects  of  the  excretions,  giving  it,  to  some  extent,  that 
protection  which  a  mucous  surface  affords ;  it  also,  perhaps 
better  than  any  other,  preserves  the  continuity  between  the 
opened  end  of  the  rectum  and  the  external  parts,  for  the  free 
passage  of  the  faaces.  The  fulfilment  of  these  indications  is 
absolutely  essential  to  the  success  of  the  operation. 

After  the  hollow  instrument  has  been  used  for  some  time, 
or  until  complete  cicatrization  has  taken  place,  it  may  be  laid 
aside,  and  the  finger,  or  the  wax  or  elastic  bougie  occasionally 
passed,  in  order  to  preserve  the  passage  patulous. 

9.  The  Liability  to  Coarctation.  To  prevent  coarctation  or 
obliteration  of  the  newly-formed  canal,  constitutes  the  most 
difficult,  troublesome,  and  serious  part  of  the  after  treatment 
of  this,  the  ordinary  method  of  operating,  and  a  great  obstacle 
to  the  success  of  the  operation,  especially  in  all  instances  in 
which  the  blind  sac  of  the  rectum  has  been  found  at  consid- 
erable depth  from  the  external  surface.  Mr.  Benjamin  Bell 
especially  directs  attention  to  this  diflaculty  in  the  two  cases 
upon  which  he  successfully  operated.  [  Vide  Cases  XXX— 
XXXI.^  Mr.  Miller,  of  Methven,  has  recorded  an  interestinir 
case  of  this  character,  in  which  the  tendency  to  the  closure 
of  the  newly-formed  opening  was  so  great,  that  he  was  com- 
pelled to  repeat  the  operation  ten  times  before  the  little  pa- 


THE   THIRD    SPKCIE3    OF   MALFOKMATIOls'.  lOO 

tient  was  eight  mouths  okL  [Vide  Case  CXXXVII?\  An- 
other simihir  and  interesthig  case  is  rehited  by  Mr.  Francis 
McEvoy.  \yid6  Case  XXXI V?[  M.  Velpeau  says,  '-The 
last  portion  of  the  intestine  can  never  be  reestablished  but  in 
a  ver}^  imperfect  manner.  It  is  a  listula  which  we  substitute 
in  place  of  the  natural  tube.  The  species  of  mucous  surface 
which  ultimately  becomes  developed,  can  but  very  feebly 
represent  the  tunics  of  the  anus.  Though  the  system  be  inca- 
pable of  entirely  closing  up  stercoral  fistulas,  it  has  a  constant 
tendency  to  diminish  them,  so  that  they  soon  become  nothing 
more  than  mere  ducts  for  the  passage  of  fluid  matters.  The 
absence  of  the  sphincter,  especially,  is  a  fatal  bar  to  success. 
When  this  is  the  case,  it  would  be  extremely  probable  that 
the  anus  w^hicli  had  been  artificially  reestablished  would  be 
one  of  the  most  difficult  to  keep  open."     {Op.  cit.  p.  1090.) 

Some  surgical  writers  declare,  however,  that  if  the  opera- 
tion is  properly  performed — that  is,  if  the  incisions  are  suffi- 
ciently extensive,  no  contraction  or  disposition  to  obliteration 
of  the  artificial  canal  will  take  place,  and  consequently  no 
difficulty  will  be  experienced  in  keeping  it  pervious.  Among 
those  authors  may  be  named  the  celebrated  French  surgeon 
Dionis.  {Cows  d''  Operations  de  Chirurgie.  Edit.  IV.  me. 
par  La  Faye.  tome  I.  p.  391.  Paris :  1740.)  And  also  Mr. 
Malyn,  a  late  English  surgeon  and  writer,  who  says — ''  Great 
stress  is  laid  by  some  authorities  on  keeping  a  plug  in  the 
anus,  to  prevent  the  reunion  of  the  sides  of  the  wound.  This 
misht  be  of  some  service  if  the  incisions  were  so  slight  as 
only  to  serve  for  present  exigencies ;  as  then  the  remainder 
of  the  cure  must  be  effected  by  dilatation.  But  when  the 
operation  has  been  properly  performed,  there  is  no  occasion 
for  a  plug,  inasmuch  as  the  cut  having  passed  across  the 
direction  of  the  muscular  fibres,  they  will  retract  and  drag 
the  faces  of  the  incision  away  from  each  other,  so  that  if  the 
object  were  to  reunite  them,  it  would  be  most  difficult  to  ac- 
complish."    {Cyclopaedia  of  Practical  Surgery.     By  W.  B. 


110  THE   THIRD   SPECIES    OF   MALFOEMATIOX. 

Costello,  2L  D.     Vol.  I.    Article^  AnxLS.   p.  3-i3.     London  : 
1841.) 

It  appears  to  me,  however,  that  such  an  operation  as  Mr. 
Malyn  here  recommends  would  completely  destroy  the  power 
of  the  sphincter  ani  muscles,  if  they  existed,  and  ever  after 
occasion  incontinence  of  faeces,  an  infirmity  which  might  not 
be  preferable  to  death. 

10.  The  Objections  of  M.  Amussat.  Twenty-five  years  ago 
the  celebrated  JVI.  Amussat,  whose  highly  improved  method,  it 
will  be  observed,  I  have  in  part  recommended  and  adopted, 
discarded  the  ordinary  operation  in  these  cases,  in  conse* 
quence  of  what  he  conceived  to  be  the  insurmountable  difii- 
culties  that  always  attend  it.  He  declared  most  positively, 
that  the  ordinary  method  by  simply  incising  down  upon  the 
rectum,  when  the  blind  sac  of  this  organ  laid  deep,  was  en- 
tirely inefficient,  and  ultimately  attended  with  uniform  fail- 
ure. This  he  attempted  to  establish  and  maintain  in  a 
remarkably  able  paper,  which  was  read  before  the  Academy 
of  Sciences  on  the  second  day  of  ]S"ovember,  1835,  styled — 
"  Histoire  d'une  Operation  d? Anus  artijiciel  2>'''':i'i^^ue  cweo 
succes  par  un  nouveau  Precede^  dans  un  cas  d^ Absence  con- 
geniale  de  VAnus  /  suivie  de  quelqnes  reflexions  su?'  les  Obtu- 
rations du  Rectum.''''  {Gazette  Medicate  de  Paris.  Ifovetn- 
bre  28, 1835.) 

It  appears  that  M.  Amussat  was  first  led  to  reject  the 
ordinary  operation,  from  the  circumstance  of  his  having  per- 
formed it  unsuccessfully  upon  two  cases,  in  each  of  which  the 
rectum  terminated  between  one  and  a  half  and  two  inches 
from  the  cutaneous  surface  of  the  perinseum.  The  operation, 
he  says,  was  performed  in  the  ordinary  manner,  by  simply 
cutting  down  on  the  rectum,  but  both  infants  died  jaundiced 
in  a  few  days,  which  event  he  attributed  to  the  absoi-ption  of 
the  bile  and  the  meconium,  consequent  upon  their  coming  in 
contact  with  a  wound  of  such  considerable  extent.     That  M. 


THE   THIRD   SPECIES   OF   MALFOliMATION.  Ill 

Aniussat,  however,  lias  considerably  exaggerated  the  imper- 
fections, difficulties  and  failures  of  the  ordinary  method,  will 
be  sufficiently  obvious  when  we  take  into  consideration  the 
success  which  has  attended  it  in  numerous  instances  ;  some  of 
them,  it  will  be  observed,  were  of  a  most  discouraging  char- 
acter, the  operation  having  been  performed  under  the  most 
unfavorable  and  embarrassing  circumstances.  lie  has  in  thus 
imputing  uniform  failure  heretofore  to  this  operation,  done 
injustice  to  the  several  able  and  distinguished  surgeons  who 
have  in  several  instances  performed  it  so  successfully. 

The  main  objection  that  ]\^.  Amussat  urges  against  the  op- 
eration, and  the  one  which  led  him  to  reject  it  altogether,  is, 
that  the  bile  and  the  meconium  are  liable  to  be  absorbed  by 
the  fresh  surfaces  of  the  wound  made  by  the  operation,  and 
thus  cause  jaundice,  or  mortal  degeneration  of  the  blood.  It 
was  to  this  circumstance  alone  he  attributed  the  loss  of  his 
two  cases,  already  alluded  to.  M.  Amussat,  however,  failed 
to  verify  this  positive  declaration  of  his,  by  2^  jpost-mortem  ex- 
amination of  the  biliary  organs  of  his  two  unfortunate  cases. 
I  do  not  believe  that  the  icteroid  appearance  of  these  cases 
had  anything  whatever  to  do  with  his  operation — that  this 
appearance  of  the  skin  was  not  caused  by  absorption  of  the 
bile  and  the  meconium,  in  the  manner  he  imagined.  They 
doubtless  would  have  died  jaundiced  had  he  not  performed 
the  operation,  for  it  is  a  notorious  fact  that  by  far  the  largest 
number  of  such  cases  have  this  yellow  tinge  of  the  skin,  inde- 
pendently of  any  operation.  Nearly  all  such  cases,  unless 
completely  relieved  by  the  operation,  die  jaundiced ;  the  jaun- 
dice, however,  is  neither  the  result  of  the  absorbtion  of  the 
bile  and  the  meconium  by  the  wound,  nor  is  it  the  immediate 
cause  of  death.  The  operation,  if  timely  and  judiciously  per- 
formed, instead  of  inducing  jaundice,  is  the  first  step  towards 
removing  it,  if  it  already  exists,  and  of  preventing  it,  if  it  does 
not  exist.  The  icteroid  tinge  of  the  skin  in  these  instances 
may  be  the  result  of  the  too  long  retention  of  the  meconium 


112  THE   THIRD    SPECIES    OF   MALFORMATION. 

in  the  intestines,  or  it  may  be  tlie  result  of  inflammation  of 
tlie  umbilical  vein,  or  of  the  biliary  ducts ;  indeed,  this  icter- 
itious  appearance  is  a  phenomenon  not  unusual  in  infants  of 
from  two  to  three  days  old,  even  when  no  malformation  at  all 
exists,  doubtless  consequent  upon  a  temporary  excess  of  the 
colorino;  matter  of  the  bile  in  the  serum  of  the  blood,  for  I 
have  myself  often  observed  in  the  new-born  the  whole  surface 
of  the  body,  as  well  as  the  tunica  conjunctiva,  to  acquire  a 
yellow  hue,  more  or  less  intense,  the  result  of  a  slight  or  a 
severe  acute  hepatitis  w^hich  obstructs  the  circulation  of  the 
bile  and  causes  its  passage  intq  the  blood.  About  one-third 
of  all  infants  born,  are  more  or  less  affected  with  icterus.  The 
main  objection  of  M.  Amussat,  to  the  ordinary  operation  uj^oii 
this  ground  has,  therefore,  in  my  opinion,  no  foundation  in 
truth.  His  objections,  however,  to  the  operation,  on  account 
of  the  liability  to  closure  of  the  newly  made  passage,  to  infil- 
tration and  the  formation  of  stercoral  abscesses  in  the  vicinity 
of  the  artificial  anus,  are  much  more  plausible,  for  these  acci- 
dents sometimes  certainly  occur,  and  they  are  serious  obsta- 
cles to  the  success  of  the  ordinary  operation. 

11.  The  Method  of  M.  Amussat.  The  chief  feature,  or  pecu- 
liarity of  the  method  of  M.  Amussat,  is  the  application  to  the 
anus  of  the  principles  and  the  practice  which  Dietfenbach  ap- 
plies to  the  lips,  in  cases  of  narrowing  and  closure  of  the 
mouth.  {Traits  sur  Vart  de  restaurer  lea  defformites  de  la 
face,  par  deplacement.    Montpellier :     1842.     Atlas.) 

I  have  already  shown  at  the  commencement  of  this  section, 
that  M  Amussat  advises  the  blind  end  of  the  rectum  when 
found,  to  be  detached  from  its  adhesions  for  the  purpose  of 
bringing  it  down  even  with  the  external  opening  made  by  the 
incision,  and  there  attaching  its  mucous  membrane  by  sut- 
ures to  the  lips  of  skin  formed  by  the  edges  of  the  cutaneous 
wound.  It  will  thus  be  seen  that  the  object  of  M.  Amussat's 
method  is  to  supply  the  whole  track   of  the   artificial  canu'. 


TIIK   TIIIKD   SPECIES   OF   M^y.FORMATION.  113 

with  the  luitunil  tissues,  wliich  in  these  cases  is  the  sreat 
desideratum,  these  tissues  being  already  prepared  and 
adapted  to  the  exercise  of"  tlie  functions  Avliich  tliey  are 
designed,  and  will  be  called  upon  to  perform. 

It  must  be  admitted  that  M.  Amussat's  modification  of  tlie 
ordinary  proceeding  is  in  several  respects  a  most  decided  and 
most  admirable  improvement — that  it  is  highly  ingenious  and 
deservedly  meritorous  ;  but  it  also  must  be  admitted,  how- 
ever, that  it  cannot  be  universally  adopted  ;  that  it  is  by  no 
means  void  of  danger,  for  by  depressing  the  rectum  too  much, 
serious  if  not  fatal  consequences  might  be  the  result ;  and 
that  it  is  not,  in  every  case,  as  essentially  necessary'-  to  success 
as  he  intimates.      It  will  doubtless  succeed  well  in  all  cases 
in  which  the  cul-de-sac  of  the  rectum  does  not  lie  deep,  and 
having  no  adhesions,  floats  loosely  in  the  pelvic  cavity,  as  it 
does  in  some  instances ;  or  when  it  can  easily  be  separated 
from  its  adhesions,  or  these  themselves  are  capable  of  being 
stretched,  so  that  it  can  be  drawn  down  without  much  force 
or  difficulty  to  its  external  position  in  the  perinseum.      It  is 
however,  on  the  contrary,  impracticable  when  there  is  consid- 
erable deficiency  of  the  rectum,  the  very  cases  in   which  it 
would  be  the  most  essential.     The  great  difficulty  in  such 
cases  is  elongating  the  rectum  sufficiently.     In  order,  how- 
ever, to  obviate  this  difficulty,  M.  Amussat  advises  that  the 
artificial  anus  be  established  in  the  coccvofeal,  instead  of  the 
perinEeal  region,  in  as  much  as  the  blind  end  of  the  rectum, 
lying  nearer  the  former  than  the  latter,  would  consequently 
have  a  shorter  distance  to  traverse  in  reaching  the  surface, 
by  being  drawn  directly  backward,  than  by  being  pulled 
downwards  to  the  natural  situation  of  the  anus.      He  there- 
fore advises  the  external  incision  to   be  made  immediately 
anterior  to  the  coccyx,  or  to  the  left  of  this  bone.     He  even 
advises  the  excision  of  the  os  coccygis,  if  necessary  to  gain 
room  ;    having  himself  on  one   occasion    for   this   purpose, 

removed  the  extremity  of  this  booe   in  a  case  of  this  kind. 
8 


Hi  THE   THIKD   SPECIES   OF  MALFORMATION. 

The  child,  however,  died  a  few  days  afterwards.    [  Vide  Case 
CXLIV.] 

It  will  be  observed  that  M.  Amussat,  unlike  M.  Roux  de 
Brignoles,  in  this  respect,  attaches  no  importance  whatever 
to  securing  for  the  benefit  of  the  artificial  anns,  the  sphincter 
muscles,  by  bringing  down  the  end  of  the  rectum  into  imme- 
diate contact  with  them  ;  but  on  the  contrary  deprecates  any 
attempt  of  the  kind.  For  the  purpose  of  making  his  favorite 
method  sufhciently  elastic  to  extend  to  all  cases  in  which  the 
end  of  the  rectum  can  be  reached,  he  would  sacrifice  both 
the  natural  situation  of  the  anus,  and  the  sphincter  ani  mus- 
cles. But  to  discard  these  invaluable  adjuncts,  on  this 
•account  merely,  when  they  could  be  preserved  by  the  ordi- 
nary method,  or  by  that  of  M.  Roux,  would  be  a  great  error 
which  should  itself  be  discarded  ;  for  without  these  it  is 
impossible  to  establish  the  complete  function  of  the  artificial 
anus.  The  practice  of  M.  Amussat,  however,  corresponds 
with  his  theory  on  this  subject,  which  is  that  the  interior 
outlet  of  the  body  is  disposed  in  such  a  manner,  indepen- 
dently of  its  muscular  apparatus,  as  to  favor  voluntary  reten- 
tion of  the  faeces  ;  consequently  that  the  power  of  retaining 
and  controling  the  discharge  of  the  faeces  does  not  solely 
depend,  upon  the  sphincter  muscles,  for  patients  have  been 
known  to  retain  control  over  the  alvine  evacuations,  after  the 
excision  of  the  inferior  extremity  of  the  rectum.  He  tliere- 
fore  comes  to  the  conclusion  that  the  same  power  will  exist 
after  his  operation  for  artificial  anus  in  the  coccygeal  I'egion, 
and  hence  he  imagines  there  is  no  necessity  for  the  sphincter 
muscles.  In  this  it  will  be  seen  he  differs  but  little  in  opin- 
ion from  Mr.  O'Beirne.  {JVew  Views  of  the  Process  of  Defe- 
cation.    Dublin ,  1833.) 

It  was  the  dutv  of  M.  Amussat,  however,  to  have  estab- 
lished  his  theory  by  undoubted  facts,  before  drawing  such 
conclusions  from  it.  This  he  never  did,  and  until  he  does, 
whether  the  operation  is  performed  by  the  ordinar}-^  method. 


THE   THIRD    SPECIES   OF   MALFOUMATION.  115 

or  by  Ills  own,  tlie  iiutural  Bituiitiuii  ot"  the  uiius  in  the  periii- 
seal  region  should  be  selected,  and  the  sphincter  muscles,  if 
they  exist,  should  always,  if  possible,  be  secured,  so  that  the 
power  of  retaining  the  faeces  by  the  artificial  anus  would 
without  doubt  fail  to  be  preserved. 

The  first  case  upon  which  M.  Amerssat  executed  his  inval- 
uable operation,  was  a  very  complicated  and  difficult  one  ; 
and  as  it  is  highly  interesting  and  most  fully  illustrates  his  pecu- 
liar method,  I  have  produced  it  entire.     [  Vide  Case  XLII.\ 

12.  The  Ojyeration  of  M.  Amussat,  performed  hy  others.  Mr. 
Waters  of  Parsonstown,  England,  records  a  case  of  imperfor- 
ate anus  and  rectum,  in  which  in  1.842  he  performed  a  similar 
operation  to  that  performed  by  M.  Ainussat  seven  years  pre- 
vious, (1835.)  Complete  success  attended  this  operation.  It 
is  said  that  Mr.  Waters  was  not  at  all  aware  of  the  method  of 
M.  Amussat  when  he  performed  this  operation,  but  was  led  to 
adopt  the  plan  he  followed,  solely  by  his  own  reflections 
upon  the  case.  This  may  all  be  true,  and  it  may  afi'ord 
another  example  that  good  surgeons  every  where  think  alike 
and  come  to  the  same  conclusions.  One  thing  however  is 
certain,  that  the  operation  of  M.  Amussat  was  notorious  for 
seven  years  in  France,  previous  to  that  performed  by  Mr.  Wat- 
ers, and  that  the  Channel  only  divided  the  two  surgeons.  I 
have  presented  Mr.  Waters'  case  in  full.  [  Vide  Case  XLIII.] 

Mr.  W.  G.  Smith  of  Vauxhall-Walk,  London,  in  1846, 
adopted  in  part  the  method  of  M.  Amussat,  in  a  very  extra- 
ordinary case.  Complete  success  was  the  result  of  the  oper- 
ation.    [^Vide  Case  XL IV.] 

Mr.  West  says  that  he  was  a  witness  to  the  great  advanta- 
ges of  M.  Amussat's  method  in  a  little  boy  upon  whom  Mr. 
Shaw  operated  successfully  a  few  years  since  at  the  Middle- 
sex Hospital.  {Lectures  on  the  Diseases  of  Infancy  and 
Childhood.    Led.  XXXI.  p.  377.  Phil.  1854.) 


110  THE   THIKD   SPECIES   OF   ISIALFORMATION. 

Dr.  Hermann  Friedberg,  of  Berlin,  in  a  late  and  very  able 
essay  on  Artiiicial  Anus,  higlilj  extols  the  method  of  M- 
Amnssat,  which  he  has  more  or  less  improved  and  faithfully 
carried  out.  He  successfully  operated  on  a  grave  and  very 
interesting  case  by  this  method,  somewhat  modified  by  him- 
self, and  as  this  case  fully  illustrates  his  method  of  operating, 
I  have  presented  it  in  detail,  translated  from  the  French, 
having  been  unable  to  procure  a  German  copy  of  his  work. 
[Vide  CaseXZVIL] 

Mr.  Redfern  Davies,  of  Birmingham,  England,  also  highly 
approves  of  the  method  of  M.  Amussat,  and  proposes  a  modi- 
fication of  it.  His  remarks  on  the  subject  are  practical  and 
certainly  deserve  attention.  He  did  not,  however,  adopt  his 
own  suggestions  in  a  case  of  imperforate  anus  and  rectum 
upon  which  he  operated.  [  Vide  Case  Lll?^  The  considera- 
tions, however,  which  influenced  him  not  to  do  so  in  this 
case  appear  obvious  enough.  "  The  reasons,"  says  he,  "  that 
induced  me,  at  the  time  when  the  rectum  was  opened,  to 
forgo  even  the  attempt  to  bring  it  down  were— that  I  deemed 
the  distance,  two  and  a  quarter  inches,  at  which  it  was 
situated  from  the  external  opening,  to  be  so  great  as  to 
preclude  the  possibility  of  so  doing.  Bound  down  as  the 
rectum  is  by  its  foldof  peritonseum,  the  meso-rectum,  I  feared 
to  encounter  the  almost  certain  dangers  of  peritonitis,  or 
pelvic  cellulitis,  which  must  inevitably  be  the  probable 
consequence  of  the  laceration  of  its  connective  tissues,  to 
permit  of  its  descent  for  such  a  distance.  Besides,  at  such  a 
depth,  how  great  an  uncertainty  there  must  be  as  to  what 
the  forceps  might  seize  hold  of."     And  again,  he  says  :  — 

"  With  all  due  deference  to  the  opinions  of  others,  and  in 
hopes  that  it  will  receive  whatever  of  attention  it  may  merit 
in  their  hands,  I  beg  to  lay  before  the  opinion  of  my  moi-e 
experienced  professional  brethren  the  following  modification 
in  the  operative  interference  usually  adopted  in  these  cases, 


THE   TIIIliD  SPECIES    OF   MAI.FOKMATIOX.  117 

wliicli  T  li;i(l  intended,  had  the  patient  survived  a  sufficient 
length  of  time,  to  carry  into  clFect.  As  far  as  can  be  judged 
by  the  evidence  of  the  published  cases,  death  is  the  conse- 
quence of  different  causes,  according  as  the  rectum  is,  or  is 
not,  brought  to  the  opening  of  the  wound.  If  it  is,  death 
ensues  from  the  injuries  inflicted,  by  so  doing.  If  it  is  not, 
death  ensues,  but  secondarily,  iu  consequence  of  the  difficulty 
to  defecation  being  only  partially  removed.  I  would  propose, 
therefore,  to  combine  these  two  procedes,  and  endeavor  to 
obtain,  by  extending  the  operative  measures  over  a  consider- 
able time,  immunity  from  the  evils  of  both :  viz.,  supposing, 
in  the  first  instance,  that  an  opening  had  been  made  (as  was 
done)  into  the  rectum,  nature  being  relieved,  had  not  other 
influences  intervened,  the  child  would  have  lived  pro  tern.  ; 
but  then  comes  into  consideration  the  subsequent  difficulty  in 
passing  the  stool,  owing  to  a  gradual  narrowing  of  the  passage. 
All  this  is  said  to  be  due  to  the  mucous  membrane  not  beiuo- 
continuous  with  the  outlet. 

To  remedy  this,  therefore,  when  the  parts  have  recovered 
from  the  efiects  of  the  first  operation,  introduce  a  pair  of 
forceps,  and,  seizing  hold  of  the  lips  of  the  opening  into  the 
rectum,  endeavor  to  bring  it  down,  not  by  one  vigorous  and 
decisive  holding  on  by  the  forceps,  and  by  main  force 
bringing  the  gut  to  the  external  orifice,  but  by  gently  and 
repeatedly  soliciting  its  descent,  introducing  the  forceps  at 
certain  intervals,  and  gradually  endeavoring  to  accomplish 
the  end.  If  the  rectum  can  be  so  moved  from  its  position, 
and  be  brought  lower  down  in  the  pelvis  (and  so  by  repeated 
attempts  it  has  been  proved)  by  one  forcible  extension,  and 
even  that  sometimes  crowned  by  success,  how  much  more 
liively  is  it  that  success  should  attend  the  proceeding,  when, 
by  the  almost  imperceptible  tractions  made  upon  it,  the  great 
causes  of  failure,  viz.,  peritonitis  and  pelvic  cellulitis,  would 
be  removed,  owing  to  the  small  amount  of  disturbance  that 


lis  THE   THIRD    SPECIES    OF   MALFORMATION. 

■would  take  place  in  the  soft  parts.  Although,  as  far  as  I  am 
aware,  this  procede  by  successive  stages  has  never  before 
been  broached  in  any  writings  on  the  subject,  the  idea  was 
taken  from  a  case  reported  in  the  "  Lancet,"  vol.  i.  p.  493, 
1S46,  [  Vide,  Case  XLIY^  in  which  an  incision  was  made  into 
the  perineum  for  a  distance  of  three  inches,  and  on  the  second 
day  an  attempt  was  made,  by  gently  pulling,  to  draw  down 
the  gut,  which  was  not,  however,  fastened  to  the  external 
opening.     One  month  afterwards  the  child  was  doing  well. 

I  am  fully  aware  that  there  is  a  vast  deal  of  essential 
diflference  between  this  procede  and  the  one  I  advocate  : 
nevertheless,  accomplishing  the  end  by  successive  stages,  is 
in  this  case  shadowed  out,  and  will,  I  trust,  assume  a  definite 
status  in  surgery."  {Ediiiburgh  Medical  Journal,  March, 
1S5S.     m.  XXXIILp.  811.) 

Although  M.  Amussat,  in  his  very  able  and  highly  inter- 
esting and  practical  paper  already  alluded  to,  laid  down  his 
beautiful  process  for  the  establishment  of  an  artificial  anus  in 
the  perineeum,  and  demonstrated  its  practicability  and  com- 
plete success  in  the  very  first  case  upon  which  he  executed 
it ;  yet  strange,  passing  strange,  he  never  afterwards  in  other 
cases  pursued  this  method  to  its  consequences,  but  in  place  of 
it,  adopted  and  practiced  colotomy.  He  thus  seemed  to  have 
designed  and  built  a  most  beautiful  superstructure,  merely  to 
gaze  upon  it  for  a  moment,  and  then  to  demolish  it. 

13.  The  Operation  hy  Puncture.  Perinseal  puncture  was  the 
earliest  method  of  operating  in  cases  of  congenital  closure  of 
the  anus  or  the  rectum,  and  is  still  recommended  and  per- 
formed by  some  surgeons  of  the  present  day.  They  use  for 
this  purpose  a  trocar,  a  pharyngotomus,  a  lancet,  or  some 
other  piercing  instrument,  and  thrusting  it  into  theperinseum 
at  the  normal  place  of  the  anus,  they  make  it  follow  the 
natural  direction  of  the  rectum  with  the  intention  of  penetrat- 
ing the  end  of  this  intestine,  should  it  be  present  and  in  its 
normal  position. 


THE   TIIIllD    SPECIKS    OF   MALFOKMATION.  110 

The  metlioJ  by  puncture  is  recommended  in  consequence 
of  its  being  very  simple  and  quickly  executed  in  urgent  cases, 
even  by  tlie  young  and  inexperienced  surgeon.  There  are, 
however,  but  few  cases  on  record  in  which  this  operation  lias 
succeeded  ;  it  should  therefore  be  entirely  abandoned  at  this 
day,  with  the  exception  of  those  cases  in  which  the  end  of 
the  rectum  can  be  appreciated  both  by  the  sight  and  the 
touch — that  is,  in  which  it  lies  near  the  surface  and  is 
distended  with  gas  and  meconium,  Tlie  "  hlind  plunge'''  of 
such  an  instrument  into  the  perinteum  in  those  cases  in  M'liich 
it  is  aboslutely  requisite  to  penetrate  deeply,  is  a  most  hazar- 
dous proceeding,  and  one  well  calculated  to  inflict  fatal 
injury  to  some  of  the  delicate  and  important  organs  of  these 
parts.  Such  an  instrument  is  exceedingly  liable  to  perforate 
the  bladder,  especially  as  this  organ,  in  cases  in  which  there 
is  considerable  deficiency  of  the  rectum,  occupies  a  lai'ger 
space  in  the  pelvis.  There  is  indeed  a  great  deal  less  cer- 
tainty in  the  result  of  this  operation  than  perhaps  in  any 
other  in  surgery,  "When  the  trocar  or  any  instrument  of  the 
kind  is  used  in  these  cases,  the  operator  is  compelled  to 
follow  the  natural  direction  of  the  rectum,  but,  as  I  have 
shown  elsewhere,  this  intestine  often  deviates  from  its  normal 
course.  Should  the  rectum  be  further  in  front  or  to  either 
side  than  natural,  it  might  be  missed  or  not  opened  in  its 
proper  place,  and  the  operation  of  course  would  fail,  and  the 
patient  be  lost ;  whereas  in  the  operation  by  dissection,  the 
blind  end  of  the  rectum  can  be  sought  for,  and  if  it  exist,  can 
be  found  somewhere  in  the  pelvic  cavity  within  the  safe 
limits  of  the  operation.  Of  all  other  openings  too,  those 
made  by  puncture  are  the  most  liable  to  contract  and  become 
obliterated.  Puncture  therefore,  in  my  opinion,  can  never 
be  substituted  for  dissection  in  these  cases,  without  great 
uncertainty,  risk  and  danger. 

M.  Petit,  when  speaking  of  the  operation  by  puncture,  ob- 
serves   that   it   is   very  difficult  to  find  the  right  place  for 


120  THE   THIKD    SPECIES    OF   MALFOKMATIOIS". 

inakiiii?  the  perforation  into  the  blind  end  of  the  rectum,  as  he 
o-enerally  found  it  formed  into  a  knot  in  these  cases.  For 
performing  such  an  operation,  he  recommends  a  trocar,  the 
canuhi  and  circuhir  phite  of  which  are  so  slit  open,  as  to  serve 
as  a  groove  for  a  lancet  or  bistoury  to  run  in,  to  enlarge  the 
aperture,  after  the  trocar  has  been  pushed  into  the  blind  end 
of  the  rectum.  {Memoire  de  VAoadmnie  BoyaleldeChirurgie. 

tome  I.) 

Wolf  mentions  a  very  bad  case  of  imperforation  of  the 
anus  and  rectum,  in  which  he  used  the  pharyngotome  with 
complete  success.     [  Vide  Case  LIX.I 

Yon  Schleiss,  of  Munich,  reports  a  highly  interesting  case 
of  imperforation  or  absence  of  the  rectum,  above  a  normal 
anus,  in  which  he  succeeded  admirably  by  the  happy phmge 
of  a  trocar.  [  Vide  Case  XC] 

Dr.  James  Jones,  of  New  Orleans,  Professor  of  tlie  Practice 
of  Medicine  in  the  Medical  Department  of  the  University  of 
Louisiana,  and  a  co-editor  of  the  Kew"  Orleans  Medical  and 
Surgical  Journal,  reports  three  interesting  cases  of  imperfora- 
tion of  the  anus  and  rectum,  in  which  the  operation  by  punc- 
ture M'as  performed  with  apparent  success,  but  unfortunately 
these  cases  terminated  fatally  in  a  short  time  after  the  opera- 
tion.   [  Vide  Cases  ZX,  LXL,  LXXX  VIII.'\ 

14.  Modification  of  the  Operation  l>y  Puncture.  The  late 
able  and  distinguished  surgeon,  A.  Copeland  Hutchison,  whom 
I  have  already  several  times  quoted,  proposes  a  modification  of 
the  operation  by  puncture.  His  method  is  to  use  the  trocar 
after  iiaving  made  an  incision  in  the  ordinary  manner  with 
the  scalpel  a  certain  depth  without  finding  the  rectum.  He 
says — "  After  having  cut  to  the  depth  of  about  an  inch  and  a 
half  with  the  scalpel,  which  will  be  as  deep  as  can  be  done 
with  safety  with  tin's  instrument,  and  there  is  no  appearance 
of  meconium ;  we  should  then  lay  aside  the  scalpel  and 
recommend   the   introduction  of  the  point  of  a  middle-sized 


THE   THIRD   SPECIES   OF   MALFOKMATION,  121 

common  trocar  to  the  l)ottom  of  such  incision.  This  instrn- 
ment  should  then  he  puslied  gently  upwards  and  hackwards, 
inclining  rather  to  the  left  of  the  hollow  of  the  sacrum  and 
natural  descent  of  the  rectum,  as  far  as  the  surgeon  lliinks  it 
prudcMit,  or  nnlil  he  imagines,  from  a  want  of  resistance  to  the 
force  employed,  that  he  has  penetrated  the  gut."  {Oj).  cit. 
p.  2(jO.) 

It  will  he  perceived  that  the  process  of  Mr,  Hutchison  does 
not  differ  very  essentially  from  the  ordinary  operation  by  dis- 
section, and  hut  little  from  that  of  Benjamin  Bell;  consisting 
mainly  in  this — that  he  considers  it  too  unsafe  to  carry  the 
incisions  with  the  scalpel  heyond  one  inch  and  a  half,  and 
that  from  this  point  the  trocar  is  the  best  and  safest  instru- 
ment. He  operated  successfully  on  a  case  of  imperforation 
of  the  anus  and  rectum,  Mdiicli  I  have  given  entire,  and 
which  will  illustrate  his  method  of  operating,  and  prove 
highly  interesting  on  account  of  the  great  depth  which  had 
to  be  cut  through,  before  the  blind  end  of  the  rectum  was 
penetrated.    [  Vide  Case  XXXVI.] 

Dieffenbach  has  also  modified  the  operation  by  puncture. 
He  coiftmences  the  operation  in  the  perinseum  by  a  small 
crucial  incision,  excises  the  flaps  to  make  more  room,  and 
continues  the  depth  of  the  crucial  incision,  esj)ecially  the  lon- 
gitudinal one,  directing  it  graduall}'-  backwards  until  he 
reaches  one  inch  in  depth.  If  no  evacuation  of  fsecal  matter 
takes  place,  he  then  lays  aside  the  bistoury  for  a  small  trocar, 
and  making  a  firm  compression  of  the  abdomen,  pushes  the 
instrument  upward  and  backward  from  the  bottom  of  the 
wound,  following  the  concavity  of  the  sacrum  for  a  depth  of 
an  inch  and  a  half  to  two  inches.  After  the  stilette  is  with- 
drawn from  the  canula,  he  introduces  a  large  solid  silver 
sound,  and  endeavors  by  this  means  to  reach  the  cavity  of  the 
pelvis.  When  by  plunging  the  stilette  yet  further,  a  measure 
which  he  regards  as  very  hazardous,  he  does  not  reach  the 
rectum,  he  withdraws  the  canula,  introduces  into  the  canal  a 


122  TIIE   THIRD   SPECIES    OF   MALFORMATION, 

piece  of  soft  sponge,  and  postpones  the  rest  of  the  operation 
to  the  next  day.  If  notwithstanding  the  distention  jjroduced 
hj  the  sponge,  lie  perceives  no  intestinal  extremity  in  motion, 
from  the  pressure  of  faecal  matter  which  fills  it,  he  closes  the 
wound  with  pieces  of  adhesive  plaster,  and  has  recourse  to 
colotomy.  But  if  the  sound  penetrates  into  a  cavity,  and  is 
easily  introduced  for  some  distance,  and  if  a  little  meconium 
flows,  he  proceeds  to  enlarge  the  wound.  In  order  not  to 
lose  the  opening,  he  withdraws  the  canula  upon  the  sound, 
which  he  leaves  in  place,  introduces  by  its  side  a  large 
grooved  director,  withdraws  the  solid  sound,  places  the 
director  in  the  hands  of  an  assistant,  and  following  the  groove, 
introduces  into  the  rectum  a  strait  blunt-pointed  bistoury  and 
enlarges  on  four  sides  the  wound  made  with  the  trocar.  When 
at  last  the  opening  is  sufficiently  large  to  allow  a  perfectly 
free  passage,  he  injects  with  tepid  water,  by  means  of  a  short 
elastic  canula,  evacuates  the  bowel  as  thoroughly  as  possible, 
and  then  by  means  of  the  sound  inserts  a  pledget  of  lint 
besmeared  with  cerate.  If  it  is  possible,  he  brings  down  the 
opened  end  of  the  rectum,  and  unites  it  to  the  edges  of 
the  wound  in  the  skin.  {Die  Operative  Chirurgie.  Band.  I. 
S.  673.    Lei2)zig :  1845.) 

15.  Failure  to  foi^n  a  Perinceal  Artificial  Anus.  Should  the 
surgeon,  in  consequence  of  the  absence  or  the  great  dejDth  of 
the  rectum,  fail  to  reach  it,  and  consequently  fail  to  establish 
an  artificial  anus  in  the  perinseal  region  by  the  directions  and 
improved  method  I  have  already  presented  for  this  purpose  ; 
or  should  the  case  be  of  such  a  character,  that  these  measures, 
or  the  ordinary  operation  would  be  considered  altogether  im- 
practicable, he  should  then  proceed  at  once  to  form  an  artifi- 
cial anus  in  the  abdomen.  This  operation,  however,  should 
never  be  performed  but  upon  the  most  mature  reflection, 
after  having  made  a  most  minute  and  careful  examination  of 
the  case,  and  from  a  firm  conviction  that  it  offers  the  only 


THE   THIRD   SPECIES   OF   MALFORMATION.  123 

terms  upon  ■which  tlie  life  of  the  little  patient  can  he  pnr- 
cliased.    [  Vide  the  chapter  on  ^^ Abdominal  ArtlJiQial  Anus.''^^ 


SECTION    V. 

CASES     AND     REMARKS. 

Case  XXVIII. — M.  Fenerly  reports  the  following  very  in- 
teresting case  of  imperforate  anus  and  rectum  :' 

"  On  "the  30th  of  March,  1857,  a  male  child  was  brought  to 
M.  Archigene,  born  at  full  time  twenty-live  hours  previously. 
The  child  appeared  well  developed  and  healthy.  The  parents 
as  well  as  the  midwife  did  not  perceive  at  first  the  malforma- 
tion which  caused  them  to  call  him  in.  It  was  not  till 
eighteen  hours  after  birth,  and  when  the  child  began  to  toss 
about  and  cry,  that  the  parents  discovered  the  absence  of  the 
anal  opening. 

"  At  the  hrst  visit  the  symptoms  were  as  follows  :  The  child 
was  very  restless,  cried  violently,  and  refused  the  breast.  The 
respiration  at  first  normal,  soon  became  short  and  laborious, 
;he  skin  was  blueish,  the  abdomen  swollen  and  painfully  dis- 
tended ;  the  child  seemed  to  suffer  excruciatingly  wdth  colic. 

"  On  examination  of  the  perinfeum  there  appeared  no  mark 
or  vestige  of  an  anal  opening.  Tlie  raphe  existed  very  clearly ; 
it  commenced  at  the  inferior  extremity  of  the  coccyx,  and 
continued  into  the  perinseal  region ;  the  skin  presented  no 
change  of  structure.  No  depression  existed  at  a  point  cor- 
responding with  the  anal  orifice ;  only  when  the  child  made 
efibrts  to  cry,  a  slight  elevation  was  perceived. 

"  The  scrotum  contained  but  one  testicle,  the  right  one  was 
still  retained  within  the  ring ;  the  child  had  already  urinated 
several  times. 

"Tlie  imperforation  being  quite  evident,  M.  Archigene  and 
M.  Fenerly  proceeded  to  the  operation.  After  having  placed 
the  child  upon  the  table,  the  legs  flexed  and  separated,  M. 
Fenerly  explored  the  perinaeal  region,  and  precisely  on  the 
spot  which  raised  up,  during  an  eflort,  he  made  an  incision. 
He  first  divided  the  skin  to  the  extent  of  about  one  inch,  then 
the  underlayers  in  succession  to  the  depth  of  five-eighths  of 
an  inch,  taking  care  to  direct  the  bistoury,  at  first  perpendic- 
ularly, then  inclining  it  gradually  towards  the  sacrum,  so  as 


124  THE   THIRD   SPECIES    OF   MALFOEMATIOiq^. 

to  avoid  the  bladder,  and  following  the  usual  course  of  the 
sacrum.  The  fore-finger  which  directed  the  bistoury,  at  the 
same  time  that  it  explored  the  depth  of  the  wound,  felt  now  a 
fluctuating  point ;  into  this  the  bistoury  was  plunged,  and 
immediately  a  large  quantity  of  meconium  issued.  Ihe  child 
was  at  once  relieved,  the  respiration  became  normal,  and  the 
abdomen  decreased  in  size.  After  having  evacuated  the  intes- 
tine and  washed  out  the  rectum,  he  introduced  an  elastic 
sound  smeared  with  cerate.  The  child  sucked  vigorously  and 
slept  perfectly  well.  The  third  day  after  the  operation,  MM. 
Fenerly  and  Archigene  saw  the  child  again.  The  blueish 
color  of  the  skin  had  disappeared  ;  the  evacuations  were  nor- 
mal, yellow  in  color  and  more  moderate  in  quantity ;  the 
general  health  of  the  child  was  good.  They  continued  to  intro- 
duce an  elastic  sound  of  large  caliber. 

"  On  the  twelfth  day  after  the  operation  the  child  was  well ; 
the  wound  completely  cicatrized  without  contraction.  The 
little  patient  now  has  an  anus  whose  opening  is  nearly  five- 
eighths  of  an  inch  in  size."  {Gazette  des  Hojntaux  de  Paris. 
Aunee  1857.  A?>.  XCVIII.  p.  391.  From  Gazette  Medi- 
cate d^  Orient.) 

Case  XXIX. — The  following  very  interesting  case  is  re- 
ported by  Dr.  A.  B.  Shipman,  of  Cortland ville,  X.  Y.,  in  a 
letter  to  the  editor  of  the  "  Boston  Medical  and  Surgical 
Journal,^''  dated  October,  18i0. 

"  On  the  30th  of  October,  1838,  Elizur  Graves,  of  Solon,  in 
this  county,  consulted  me  respecting  a  child  of  his,  ^t.  three 
months,  for  a  malformation  of  the  anus,  which  was  congenital. 
It  was  not  discovered  until  some  days  after  birth,  when,  after 
repeated  exhibition  of  cathartic  medicines,  no  evacuation 
taking  place,  the  nurse,  on  attempting  to  exhibit  an  enema, 
found  no  opening.  A  practitioner  Avas  consulted,  who  gave 
►  an  unfavorable  prognosis  as  to  any  remedy,  and  the  child  was 
considered  as  among  the  incurable.  But  as  it  continued  to 
live,  and  even  to  tlu-ive,  at  the  end  of  three  months  the  parents 
brought  it  to  me.  On  examination,  there  was  no  opening 
into  the  rectum,  but  a  little  posterior  to  the  natural  situation 
of  the  anus  a  slight  projection  of  the  skin  was  observed,  which, 
on  examination,  gave  an  obscure  feel  of  fluctuation.  Tlie  skin 
was  also  slightly  inflamed.  I  advised  an  opening  into  this 
point,  which  the  parents  readily  assented  to,  and  it  was  accor- 
dingly made,  and  about  a  tablespoonful  of  pus  discharged,  but 
no  faeces  as  was  expected.  I  next  examined  the  opening  with 
a  probe,  but  could  find  no  communication  w,ith  the  bowel.  I 
next  passed  a  sharp-pointed  narrow  bistoury,  with  the  edge 


TIIK   TIIIKD    SPECIES   OF    ^fALFOltMATION.  i25 

towards  tlic  yacnim,  in  tliu  diiveti(jii  oi"  lliu  ivctuiii,  the  dis- 
tance of  tlirce  Indies.  It  was  witlidrawn,  and  the  ])oint  found 
smeared  with  foeces.  Considerable  luiiinorrhage  followed.  I 
next  introduce<l  an  elastic  g'um  catheter,  of  small  si/A'/nsini^ 
different  sizes  until  the  largest  ones  could  he  passed  without 
dithculty.  Some  warm  water  was  now  injected  through  the 
tube,  which  brought  away  a  (quantity  of  liquid  faeces.  1 
directed  that  the  tube  should  be  passed  twice  a  day,  and  an 
injection  thrown  in  each  time,  and  in  the  intervals  a  wax 
bougie  of  large  size  worn  constantly.  Tlie  next  day  after  the 
operation,  a  pint  of  faeces  escaped  at  one  time,  and  the  same 
amount  continued  to  escape  daily  for  a  week.  Before  the 
operation  the  child  had  fits  of  crying  and  straining ;  the  abdo- 
men was  also  much  enlarged  and  very  hard.  Ihese  ceased 
at  the  end  of  a  week.  The  child  was  also  troubled  with  vom- 
itings before  the  operation,  which  now  no  longer  were  pre- 
sent. The  bougie  was  persevered  in  for  four  weeks,  at  the 
end  of  wdiicli  it  was  discontinued,  and  the  child  improved 
very  fast  in  flesh ;  the  evacuations  from  the  bowels  became 
natural,  and  it  has  continued  well  ever  since.  The  control 
over  the  bowels  is  as  perfect  and  natural  as  in  any  healthy 
child. 

"  There  are  some  features  in  this  case  which  make  it  more 
than  ordinarily  interesting.  In  the  first  place,  the  length  of 
time  which  elapsed  before  the  operation,  and  the  question  how 
long  this  state  might  have  continued  without  serious  conse- 
quences to  the  life  of  the  child  ;  and  second,  whether  nature 
Avould  have  finally  effected  a  cure  by  suppuration  or  ulcera- 
tion. These  are  questions  which  may  with  propriety  be 
asked.  As  to  the  length  of  time  which  elapsed,  the  child  was 
nearly  as  large  as  ordinary  children  of  that  age,  and  w^as  not 
afflicted  with  vomiting  or  crying  more  than  many  are  who 
are  considered  healthy.  Tlie  process  of  nutrition  and  chylifi- 
cation  went  on  regularly,  and  the  fteces  were  formed  as  in 
health.  The  large  intestines  must  have  become  much  dilated 
to  have  contained  the  quantity  which  had  accumulated  in 
them. 

"  Whether  nature  would  have  accomplished  an  opening  for 
the  contents  of  the  rectum,  is  not  so  easily  answered.  I  am 
convinced  that  the  small  cavity  containing  pus  did  not  open 
into  the  rectum,  and  also  that  the  termination  of  the  bowel 
was  much  higher  than  that  of  the  abscess.  Yet  it  is  possible 
that  the  ulcerative  process  might  have  finally  done  what  was 
accomplished  by  art."  {Boston  Medical  and  Surgical  Jour- 
nal.   Vol.  XX til.  2).  210.     Boston :  1840.) 


126  THE  THIRD   SPECIES   OF   MAXFOEMATION. 

Cases  XXX — XXXI. — The  two  following  cases  of  imper- 
foration  of  the  anus  and  the  rectum,  were  successfully  treated 
by  Mr.  Benjamin  Bell.  In  both  of  these  instances  the  chief 
difficulty,  after  the  operation,  consisted  in  maintaining  the 
newly  formed  passage  patulous. 

Mr.  Bell  says,  "  I  myself  have  had  two  such  cases,  in  both 
of  which  the  gut  lay  deep,  and  in  both  I  was  fortunate  enough 
to  form  an  anus,  which  for  a  good  many  years  has  continued 
to  answer  the  purpose  sufficiently.  But  in  each  of  these  a 
great  deal  of  difficulty  was  experienced  in  preserving  the  pas- 
sage sufficiently  wide  and  open  ;  for  as  soon  as  the  dossils  of 
lint,  and  other  tents  made  use  of  for  preserving  the  passage, 
were  withdrawn,  such  a  contraction  occurred  as  for  a  consid- 
erable time  rendered  the  evacuation  of  the  fceces  extremely 
difficult.  Sponge  tent,  gentian  root,  and  other  substances 
which  swell  by  moisture,  were  at  different  times  employed, 
but  these  were  uniformly  found  to  produce  so  much  pain  and 
irritation  as  rendered  their  continuance  altogether  inadmissi- 
ble. Applications  of  this  kind  are  frequently,  indeed,  recom- 
mended in  such  cases;  but  any  person  who  has  ever  used 
them,  in  parts  so  exquisitely  sensible  as  the  rectum  always  is, 
will  readily  acknowledge  the  impropriety  of  the  advice." — 
(6>p.  cit.  ]).  278.) 

Cases  XXXII — XXXIII. — Latta  mentions  two  cases  of  this 
species  of  malformation,  in  which  he  operated  \vith  complete 
success.  He  says  he  found  it  necessary  in  both  these  cases  to 
make  an  incision  of  one  inch  and  a  half  in  depth  before  the 
rectum  could  be  laid  fully  open,  so  as  to  allow  free  exit  for 
the  faeces.  Oval  canuljB  were  introduced  and  removed  once 
every  twenty-four  hours.  In  two  months  there  was  a  cure. 
The  instrument,  however,  was  used  for  nine  months,  to  pre- 
vent contraction.  {A  Practical  System  of  Surgery.  Vol.11, 
p.  8T.     Edhiburgh  :  1795.) 

Case  XXXIV. — Mr.  Francis  McEvoy  reports  the  following 
case  in  a  letter  to  the  Editor  of  the  "  London  Lancet,'''  dated 
Balbriggan  Dispensary,  October,  1846. 

"Sir, — My  father,  who  held  the  same  medical  office  in  this 
dispensary  as  I  now  hold,  was  requested  to  see  an  infant, 
whom  he  found  with  imperforate  anus.  There  was  no  indica- 
tion whatever  of  an  opening,  no  discoloration  or  elevation, 
but  the  skin  was  quite  natural.  The  child  was  twenty  hours 
old,  and  had  had  several  convulsive  lits,  and  three  or  four 
doses  of  castor  oil,  and  some  warm  baths  had  been  adminis- 
tered.    Before  discovering  the  imperfection  which  my  father 


THE   TniRD   SPECIES    OF   MALFORMATION.  127 

was  cdlcMl  to  treat,  an  openiiifv  was  nia<lc,  about  an  inch  in 
Icngtli  and  half  an  inch  in  depth,  into  the  rectum,  the  meo- 
Tiiuni  was  discharged,  and  everything  else  done  that  is  usually 
reconitnended.  The  case  progressed  favorably  for  six  or  eiglit 
weeks,  when  the  anus  l)egan  to  exhibit  symptoms  of  closing, 
and  tiiuilly  did  close,  despite  every  means  to  keep  it  open. 
On  the  day  after,  an  abscess  formed,  and  pointed  about  a 
quarter  of  an  incli  anterior  to  the  junction  of  the  scrotum  with 
the  perinaaum,  which,  being  opened,  gave  exit  to  a  quantity 
of  very  offensive  feculent  matter,  which  still  continues  dis- 
charging from  the  same  oritice.  The  boy  is  now  fifteen  years 
of  age,  enjoys  excellent  health,  suffers  no  inconvenience  or 
annoyance  from  this  condition  of  the  parts,  retains  his  i'sQCcs 
well,  and,  in  tine,  has  as  good  a  sphincter  as  man  need  desire. 
Last  spring  he  sailed,  accompanied  by  his  parents,  for  Amer- 
ica, in  sound  health.  I  thus  trespass  on  your  columns,  from 
the  case  being  recalled  to  my  recollection  on  seeing,  in  The 
Lancet  of  August  last,  under  the  head  of  "  British  Journals," 
a  case,  operated  on  by  M.  Amussat,  of  Paris,  in  which  reten- 
tion was  complete,  and  which  has  since  been  under  the  obser- 
vation of  Sir  P.  Crampton."  {London  Lancet.  Vol.  LV.  i?. 
568.     December:  18i6.) 

Case  XXXY. — The  following  interesting  case  of  imperfor- 
ation  of  the  anus  and  the  rectum,  \vas  communicated  by  Dr. 
John  P.  Campbell,  of  Flemingsburg,  Ky.,  to  Dr.  Samuel 
Brown,  of  Lexington,  Ky.,  in  a  letter  dated  March  9th,  1801. 
upwards  of  three  months  after  the  operation.  This  letter  was 
subsequently  published  in  the  "Medical  Eepository,"  one  of 
the  oldest  medical  journals  in  this  country,  and  is  as  follows  : 

"  November  23,  1800,  I  was  called  to  visit  the  child  of  Mr. 
Hutson,  in  the  vicinity  of  this  place,  on  the  second  day  after 
the  birth.  The  case  was  an  imperforate  anus.  As  an  opera- 
tion was  inevitable,  the  next  day  was  determined  upon  for 
that  purpose.  On  the  third  day,  when  I  went  to  operate,  the 
child  was  very  fretful  and  uneasy — the  abdomen  was  much 
distended  and  discolored,  and  from  the  information  of  the 
nurse,  the  faeces  had  been  frequently  vomited  up  through  the 
day.  I  began  the  operation  by  making  a  longitudinal  incision 
on  the  place  where  the  anus  should  have  been,  which  was 
slightly  marked  by  nature.  This  incision  I  extended  in  the 
direction  of  the  os  sacrum,  with  a  lancet,  until  that  instrument 
could  be  no  longer  serviceable  ;  and  no  faeces  following  it 
when  withdrawn,  I  introduced  the  scalpel,  and  carried  it  up 
in  the  same  direction  until  I  had  the  pleasing  sensation  ot 
having  reached  a  cavity.     The  instrument  was  withdrawn, 


128  THE   THIRD  SPECIES    OF   MALFORMATION. 

and  the  niecoiiium  flowed  plentifully.  The  child  was  placed 
in  a  warm  bath  np  to  the  middle,  for  a  few  minutes;  and 
after  this  a  tallow  bougie  being  introduced  to  keep  the  orifice 
open,  the  little  sufferer  dropped  into  a  pleasant  sleep.  The 
bougie  and  warm  bath  were  continued  but  a  few  days,  with 
tlie  occasional  use  of  some  magnesia  alba  and  rhubarb,  till  the 
child  recovered,  and  every  expectation  to  be  derived  from  the 
operation  was  fully  answered.  At  this  time  the  child  does 
well,  and  the  mother  assures  me  she  observes  nothing  in  its 
present  condition  diflerent  from  that  of  others  which  she  has 
already  nursed.  My  only  fear  was  that  the  sphincter  muscle 
might  be  destroyed ;  but  I  am  now  convinced  no  inconveni- 
ence will  ever  result  from  that  quarter.  It  was  a  female 
child;  and  the  length  of  the  canula,  which  I  ascertained  by 
measuring  the  instrument,  appeared  to  be  about  three  inches." 
{Medical  Repository.      Vol.  V.    jp.  45.     Neio  York :   1802.) 

Case  XXXVI. — The  following  exceedingly  important  case 
of  imperforation  of  the  anus  and  rectum,  is  reported  by  Mr. 
A.  Copeland  Hutchinson  : 

"The  fourth  and  last  case,"  says  Mr.  Hutchinson,  "  was 
the  son  of  a  Mr.  Smith,  a  tinman  residing  at  Ko.  43  Whit- 
comb  Street,  and  hud  been  born  forty-eight  hours  when  the 
operation  was  performed,  on  the  17th  of  IS'ovember,  1823,  in 
the  presence  of  Di*.  Granville,  the  father  of  the  child,  and  the 
midwife. 

"  The  raphe  was  the  only  guide  we  had  for  the  operation, 
there  being  neither  hollow  nor  depression  to  mark  the  spot 
where  nature  had  failed  in  complethig  her  design.  Dr. 
Granville  kindly  assisted  me,  at  the  operation,  b}--  securing 
the  child,  and  keeping  its  lower  extremities  in  a  proper 
position  during  the  operation,  which  was  done  by  nuiking  an 
incision  about  an  inch  and  a  half  in  length  with  the  scalpel, 
through  the  skin  and  fat,  nearly  as  deep  as  the  incision  was 
long,  but  narrowing  it  two-thirds  at  its  fundus.  ISTot  having 
reached  the  intestine  with  the  scalpel,  and  considering  that 
we  could  not  so  safely  proceed  further  upwards  in  the  direc- 
tion of  the  gut  M'ith  that  instrument  as  with  the  trocar,  the 
latter  instrument  was  preferred,  and  directed  gently  upwards, 
backwards,  and  inclining  to  the  direction  of  the  sigmoid 
flexure  of  the  colon  for  about  an  inch  ;  when  on  withdrawing 
the  stilette,  we  found  the  intestine  had  not  yet  been  reached  ; 
the  stilette  was,  therefore,  again  passed  through  the  canula, 
■which  was  still  kept  in  the  ])arts,  and  pushed  upwards  half 
an  inch  further,  when,  from  a  want  of  resistance,  I  suspected 
tliat  we  had  at  length  succeeded,  and  on   withdrawing   the 


THE    THIKD    SPECIES    OF   MALFORMATION.  129 

stilcttc  the  second  time,  inccoiilum  iluucd  through  the  cunuhi 
in  considerable  quantity  ;  and  liere  it  was  curious  to  witness 
tlie  instinctive  straining  of  the  child  to  relieve  itself  for  tlie 
first  time,  and  whieli  wouhl  suggest  tlie  advantage  to  be 
derived  from  the  practice  of  gently  iriitating  the  external 
skin  over  the  situation  of  the  anus  in  such  cases,  with  a  view 
of  ascertaining  the  probable  distance  of  the  gut  from  the 
surface  as  before  noticed  ;  for,  on  this  occasion,  the  contorted 
features  of  the  infant  were  precisely  those  of  an  adult  who 
was  constipated,  .and  straining  to  relieve  himself. 

"  The  canula  was  secured  by  tapes,  and  retained  in  the 
parts  three  days.  It  was  then  withdrawn,  cleaned,  and  again 
introduced,  the  fiBces  passing  through  it  during  that  period. 

"  After  about  a  week  or  ten  days  the  canula  was  removed, 
and  an  old  made  sponge  tent  introduced  in  its  stead  ;  but 
whether  from  its  age,  or  from  there  being  too  much  wax  in 
its  composition,  it  did  not  expand,  and  consequently  did  not 
dilate  the  parts.  Som.e  sponge  tents  recently  made  were  also 
tried  and  likewise  laid  aside,  from  their  inefficiency.  The 
common  smooth  made  bougie  of  the  largest  size,  was,  after 
some  weeks,  substituted,  and  was  found  to  answer  the  purpose 
much  better.  The  tents  used  were  about  three  inches  and  a 
half  in  length,  and,  as  they  were  introduced  close  up  to  their 
thickest  extremity,  we  ascertained  precisely  the  distance  of 
the  intestine  from  the  surface,  by  measuring  the  tent  with  a 
scale ;  the  end  of  the  part  tinged  with  bile  indicating  the 
termination  of  the  gut,  and  the  verge  of  the  newly-formed 
anus  marking  the  length  of  the  artificial  canal,  and  w^hich  we 
found  to  be  exactly  three  inches. 

"  The  child's  bowels  were  occasionally  constij)ated  for  two 
or  three  weeks  ;  but  this  was  as  frequently  obviated  by  tlie 
administration  of  small  doses  of  the  oe  Recini.  Two  months 
had  now  elapsed  from  the  operation,  when  the  mother  was 
directed  to  introduce  the  bougie  for  a  few  hours  only,  every 
day,  and  I  then  took  my  leave. 

"  At  the  end  of  three  months  the  mother  brought  the  child 
to  my  house,  and  stated,  that  although  its  i30wels  were 
regular,  and  the  usual  quantity  of  faeces  evacuated,  she  had 
that  morning  observed,  for  the  first  time,  that  its  urine  was 
in  some  degree  tinged  Avith  faeces ;  but  on  being  further 
questioned,  she  stated  that  she  had  no  reason  to  believe  the 
urine  ever  passed  per  anum.  The  child  fed  well,  grew,  was 
healthy,  and  some  teeth  appeared  at  the  usual  period ;  yet 
still  the  urine  continued  to  be  occasionally  tinged  with  foeces, 
and  until  the  morning  of  the  day  on  wdiich  it  died,  the  29th 
9 


130  THE   THIRD   SPECIES   OF   MALFORMATION. 

September,  1823,  being  more  than  ten  months  after  the 
operation,  I  heard  of  no  circumstance  to  lead  me  to  suppose 
that  the  child  had  been  otherwise  than  well. 

"The  mother  was  reproached  for  having  forborne  to  send 
for  me  during  the  six  days  that  the  child  had  been  observed 
to  be  out  of  health  from  teething,  and  a  slight  bowel  com- 
plaint. She  replied,  that  she  did  not  conceive  the  child  to 
be  in  any  danger,  as  her  other  children,  who  are  alive  and 
healthy,  had  all,  during  dentition  suffered  in  the  same  way. 

"  It  may  be  necessary  here  to  state,  that  during  the  last 
seven  months  of  the  child's  life,  I  had  observed  that  its  evac- 
uations per  anum  were  as  healthy  and  well  formed,  or  figured, 
as  were  ever  passed  by  any  child  of  its  age. 

"  On  examining  this  child  post-mortem,  the  artificial  anus 
was  found  situated  in  a  hollow,  so  precisely  as  if  it  had  been 
originally  natural,  that  the  best  anatomist  would  have  been 
■deceived  by  it ;  and  this  fact  is  more  worthy  of  record,  when 
it  is  borne  in  mind,  that  at  the  period  the  operation  was  per- 
formed, there  did  not  appear  the  smallest  depression  or  fis- 
sure on  any  part  along  tlie  line  of  the  raphe,  both  nates  pre- 
serving a  continuous  convex  surface.  When  the  abdominal 
contents  were  exposed  to  view,  by  reflecting  tlie  divided  par- 
ietes,  a  somewhat  extraordinary  disposition  of  the  bowels  pre- 
sented itself ;  for  the  small  intestines  were,  apparently,  all 
lying  on  the  left  side,  resting  on  the  sigmoid  flexure  of  the 
colon ;  the  intestinum  rectum  was  very  large,  and  distended 
with  air,  being  at  its  widest  part,  (viz,  five  inches  above  the 
external  aperture  or  artificial  anus,)  si/x  inches  a7id  three 
fourths  in  circumference  /  and  passing  from  the  centre  above 
the  pubes  to  the  right  side,  it  rested  upon  the  cjBcum  caput 
coli ;  and  then  turned  downwards  behind  the  bladder  to  the 
artificial  anus.  The  lower  part  of  the  rectum  adhered  to  the 
bladder  by  its  peritonajal  reflection  in  the  usual  manner.  The 
sigmoid  flexture  of  the  coh)n  was  found  in  situ,  and  of  its 
natural  size,  owing  probably  to  tlie  small  intestines  resting 
upon  it ;  and  the  transverse  arcli,  though  in  its  place,  was 
also  somewhat  larger  than  natural,  and  likewise  distended 
with  air.  The  omentum  was  wanting.  The  stomach  quite 
empty  and  flaccid,  lay  hidden  by  the  arch  of  tlie  colon.  The 
small,  intestines  were  not  all  distended  with  air,  were  of  a 
healtliy  appearance,  and  almost  empty.  The  bladder  was 
empt}--,  natural,  and  adhering  to  the  pubes  up  to  its  fundus, 
evidently  pressed  into  that  situation  by  the  contact  of  the 
distended  rectum  posteriorly  ;  and  at  its  fundus  there  was 
found  a  long  round  substance  or  membrane,  something  like 
tlie  uracus  found  at  this  part  of  the  bladder  in  calves.     There 


THE   THIRD   SPECIES   OF   MALFORMATION.  13 J 

was  also  a  coiTcspoiuling  mark  in  the  interior  of  the  bladder, 
which  would  almost  lead  one  to  suppose  that  this  chord  had 
once  been  pervious. 

"  Ail  the  other  viscera  were  in  a  healthy  and  natural  state, 
there  being,  in  fact,  not  any  mark  of  diseased  action  any 
where  to  be  found  throughout  the  whole  examination,  if  we 
except  a  slight  appearance  of  inflammation  on  the  villous 
coat  of  the  great  arch  and  sigmoid  flexure  of  the  colon. 

'•Tlie  alimentary  canal  was  removed  from  the  stomacli  down- 
wards, including  tiie  artificial  anus,  with  its  surrounding  fat, 
bladder,  and  part  of  the  urethra,  with  all  their  adhesions  to 
each  other,  left  entire  ;  and,  during  this  part  of  the  examina- 
tion, we  found  the  sphincter  ani  muscle  wanting,  but  the 
levatores  ani  were  perfect  and  strong, 

"  A  section  of  the  bladder  and  urethra  was  made  anteriorly, 
when  a  small  valvular  aperture  was  discovered  communica- 
ting with  the  rectum,  and  situated  about  the  eighth  of  an  inch 
anterior  to  the  caput  galinaginis  or  verumontanum  ;  the  aper- 
ture into  the  urethra  admitting  only  of  the  passage  of  thin 
fgeces,  it  being  barely  suflicient  to  admit  the  end  of  a  com- 
mon probe,  but  from  its  valvular  structure  precluded  the 
urine  from  passing  per  anum  ;  and  not  any  appenratice  of 
fseces  having  ever  been  in  the  bUidder  was  observable ;  the 
lining  membrane  of  this  viscus  was  also  perfectly  healthy. 

"  It  is  worthy  of  remark,  that,  throughout  the  extent  of  the 
intestinum  rectum,  tlie  parietes  of  this  gut  were  conslderahlij 
tfiicher  than  usual,  but  particularly  towards  its  lower  part ; 
the  muscular  coat  being  here  probabl}''  increased  in  thickness, 
because  of  the  additional  muscular  force  required  to  project 
the  fteces  through  the  long  and  narrow  canal  from  the  ter- 
mination of  the  gut  to  the  external  parts,  a  distance  (even 
after  the  removal  of  the  parts,  and  maceration  in  spirits  for  a 
fortnight)  of  one  inch  and  two-eighths ;  and  there  appears  to 
me  to  be  no  other  way  of  accounting  for  the  shortening  of 
the  artificial  canal  sinoe  the  operation,  than  by  supposing  that 
the  lower  part  of  the  rectum  had  been,  by  its  own  muscular 
action,  forced  gradually  down  towards  the  external  part  in  the 
acts  of  stercoration ;  and  such  constant  pressure  on  this 
immense  thickness  of  adipose  matter  thereby  occasioning  the 
condensation  and  absorption  of  great  part  of  the  latter."  (  Vide 
Observations  on  the  Principal  Diseases  of  the  Rectum  and 
Anus.  By  Thomas  Copeland,  Esq.,  '^nd  Edition,  p.  107. 
London :  1814.) 

"  The  substance  through  which  the  artificial  anus  passed  was 
so  compact  and  condensed,  that  it  seemed  almost  semicartila- 
ginous  ;  and  it  is  somewhat  curious  to   observe,  in  the  prep- 


132  THE   THIRD   SPECIES   OF   MALFORMATION. 

•nratiou,  how  in  one  part  of  the  raucous  membrane  of  the  rec- 
tum approaches,  in  a  conical  form,  towards  the  verge  of  tlie 
artificial  anus;  and  how  in  like  manner,  the  external  skin 
passes  upwards  to  meet  the  descending  mucous  membrane,  so 
that  in  one  part  of  the  artificial  canal  will  be  seen  meeting 
each  other  the  villous  coat  of  the  intestine  and  the  external 
skin,  like  a  dove-tailing  of  conical  processes  ;  or,  as  Mr. 
Clift  (the  able  and  intelligent  curator  of  the  Royal  College 
of  Surgeons,  who  was  present  at  the  examination  of  the 
parts,  and  of  their  admeasurement,  as  have  been  here 
described)  aptly  remarked,  a  Vandyking  of  the  parts  into 
each  other." 

"  I  am  also  inclined  to  believe,  that  the  situation  in  which 
we  found  the  rectum  (on  the  riglit  side)  was  not  its  situation 
at  birth,  but  that  it  occupied  its  natural  place  ;  first,  because, 
from  the  direction  in  which  I  made  my  incision,  upwards, 
backwards,  and  inclining  to  the  left  side,  I  think  I  should 
not,  otherwise,  so  readily  have  struck  it  witli  the  trocar  ; 
secondly,  from  the  unusual  size  of  this  gut,  it  is  to  be  pre- 
sumed, that,  from  the  length  and  nan-owness  of  the  artificial 
anus,  and  its  frequent  distention  by  faeces,  it  may  have  been 
gradually  thrown  out  of  its  place;  thirdly,  had  it  remained 
in  its  usual  situation,  attached  to  the  sacrum,  its  muscular 
power  in  expeiling  its  contents  may  possibly  have  been  con- 
siderably lessened  ;  and  fourthly,  because,  in  a  case  of  intro- 
susception  of  the  ileum  and  cfecura  which  lately  came  under 
my  observation,  the  whole  of  the  latter  gut  and  ascending 
colon  were  lodged  in  the  left  side,  resting  upon  the  sigmoid 
flexure.  The  preperation  alluded  to  I  presented  to  the 
Koyal  College  of  Surgeons ;  and  at  tlie  same  time,  published 
a  short  account  of  the  case  in  the  Medical  and  Physical 
Journal  of  London. 

"  There  is  yet  one  more  remark,  as  it  strikes  me,  which  the 
post  mortem  examination  of  the  child  Smith  seems  to  call 
forth ;  viz,  the  obliteration  of  the  aperture  between  the  rec- 
tum and  urethra.  In  the  first  place,  it  was  so  minute,  that 
no  material  inconvenience  might  have  resulted  from  it  had  it 
remained  open  ;  secondly,  from  its  situation  in  the  urethra, 
and  the  progressive  increase  of  the  prostrate  gland  as  the 
child  grew  up  to  manliood,  it  may  by  this  circumstance  alone 
have  eventually  been  closed  ;  and  thirdly,  if  this  latter  result 
had  not  occurred,  the  stimulus  or  irritation  communicated 
to  the  part,  at  a  proper  period,  by  the  introduction  of  a  com- 
mon or  armed  bougie,  might  have  produced  the  desired  effect, 
-^-or  otherwise  the  part  might  have  been  cut  dow^n  upon,  as 
in  fistula  in  perinseo," 


THE   Tllllil)    SPECIES   OF    MALFORMATION.  133 

"  In  conclusion,  L  liuvc  only  to  ol)scrvc,  that  this  case  lias 
proved  so  highly  satisfactory  as  to  the  result  of  the  operation 
for  imperforate  anus,  notwithstanding  the  great  distance  of 
the  gut  from  the  external  parts,  that  1  should  hope  there  is  not 
any  surgeon  who  will  now  abandon  an  infant  to  its  fate,  under 
simihir  circumstances,  until  he  has  i)roceeded  with  his  incis- 
ion as  far,  at  least,  as  was  done  in  this  case,  taking  care  that 
the  incision  be  made  in  a  proper  direction, — the  operator 
being  guided  by  the  pressure  of  the  gut  on  the  finger  intro- 
duced 'into  the  wound."  ((9/>.  clt.  P.jp.  2G6— 274.) 

Case  XXXVII. — A  case  of  imperforation  of  the  anus  and 
rectum,  similar  in  many  respects  to  the  preceding  one — Mr. 
Hutchison's,  but  occurring  thirty-five  years  hxter,  was  com- 
municated to  "  La  France  Medicale,^^  and  copied  into  the 
"  Gazette  des  Ilopitaux,^^  the  editor  of  which  being  ignorant 
of  the  case  of  Mr.  Hutchison,  says  that  this  case  of  M.  Foucart 
raises  a  very  important  question  of  surgery,  at  the  same  time 
constitutes  of  itself  a  result  of  the  greatest  interest.  The  ques- 
tion is  this^ — 'When  there  is  no  indication  through  the  integu- 
ments that  the  closed  intestinal  extremity  is  placed  immedi- 
ately behind  the  obstructing  membrane,  and  when  after  hav- 
ing made  an  incision  of  a  certain  depth  the  intestine  is  not 
reached,  are  we  authorized  to  pursue  the  search  in  the  same 
direction,  or  should  we,  renouncing  the  first  attempt,  imme- 
diately proceed  to  form  an  anus  in  an  unnatural  position? 
It  has  been  seen  that  this  question  was  answered  many  years 
ago  by  Mr.  Bell,  Mr.  Hutchison  and  M.  Amussat.  Tlie  fol- 
io win  o-  is  the  case  alluded  to. 

M.  Foucart  on  the  -ith  of  February  1857,  was  called  to  see 
a  male  child,  born  on  the  preceding  evening  at  eleven  o'clock, 
and  who  from  the  moment  of  its  birth,  say  forty  hours,  had 
passed  no  meconium.  Born  at  full  time,  of  average  size,  the 
child  appeared  otherwise  perfectly  healthy.  It  did  not  seem 
to  suffer  at  all,  there  was  no  tension  or  tenderness  about  the 
abdomen,  and  it  had  sucked  several  times. 

Examination  of  the  anal  region  showed  no  trace  of  an  open- 
ing ;  the  skin  passed  from  one  nates  to  the  other,  presenting 
a  sort  of  median  raphe,  slightly  prominent,  wdiich  was  in  con- 
tinuation of  the  raphe  of  the  scrotum.  The  most  careful  ex- 
amination failed  to  discover  the  slightest  trace  of  fluctuation 
along  this  median  line  which  could  lead  one  to  believe  that 
the  inferior  extremity  ot  the  rectum  was  immediately  adja- 
cent to  the  skin.  There  being  necessity  for  prompt  action  for 
fear  of  losing  all  chance  of  success  by  delay,  M.  Foucart 
determined  to  act  at  once  as  if  he  had  only  to  do  watli  that 


IBi  THE    THIRD    SPECIES    OF   MALFOKMATIOX. 

kind  of  malfonnatioii  whicli  M.  Boyer  lias  made  the  second 
species  of  his  division,  and  which  consists  in  sinijjle  imperfor- 
ation  or  occlusion  of  the  anus  by  a  membrane  immediately 
behind  which  the  rectum  is  found.  The  usual  measures  and 
precautions  being  taken,  he  j^roceeded  with  the  operation  as 
follows.  Tlie  child  was  placed  on  its  abdomen,  across  the  lajj 
of  a  nm*se,  and  an  incision  of  about  half  an  inch  long  was 
made  in  the  antero-posterior  direction.  Tlien  gradually  layer 
by  layer,  he  reached  more  tlian  one  quarter  of  an  inch 
in  depth  without  meeting  any  vestige  of  the  intestine ; 
the  bistoury  met  only  with  cellular  tissue.  Tlie  extrem- 
ity of  the  little  finger  introduced  by  the  cutaneous  wound, 
felt  no  fluctuation  as  would  have  hai:)pened,  if  it  had  come 
in  contact  with  the  inferior  extremity  of  the  rectum.  The 
wound  being  gradually  enlarged  in  the  same  manner  as  before 
until  it  was  half  an  inch  long,  the  operator  by  means  of  a  hol- 
low sound  separated  the  tissues  forming  the  bottom  of  the 
wound,  and  introduced  the  fore-finger  to  the  depth  of  at  least 
three  quarters  of  an  inch,  but  with  no  result.  He  rested  here, 
but  by  no  means  renouncing  the  hope  of  reaching  the  intes- 
tine, notwithstanding  these  fruitless  attempts,  intending  to 
establish  an  artificial  anus  either  in  the  groin,  or  in  the  lumbar 
region  as  advised  by  Amussat.  However,  he  did  not  wish  to 
take  the  whole  responsibility  of  further  operations.  M.  Mai- 
sonneuve  being  called  in,  thought  the  hope  of  reaching  the 
lower  end  of  the  rectum  by  no  means  unreasonable,  and  re- 
solved to  push  the  attempt  yet  further. 

He  first  introduced  into  the  wound  the  blades  of  a  strong: 
pair  of  dressing  forceps,  and  opening  them  several  times  forc- 
ibly, he  endeavored  to  enlarge  the  commencement  of  the  canal 
already  made  in  the  cellular  tissue,  by  dilatation  alone  with- 
out division  of  the  tissues.  Tliis  done,  he  introduced  the  ex- 
tremity of  the  finger,  but  could  not  any  more  gain  evidence 
of  the  presence  of  the  rectum.  Then  armed  with  a  very  slen- 
der exploring  trocar,  and  following  as  near  as  possible  the 
direction  of  the  sacrum,  he  pushed  the  instrument  slowly  up- 
wards ;  at  a  certain  moment,  he  thought  he  felt  the  trocar 
enter  a  cavity.  He  withdrew  the  blade  of  the  trocar,  and- 
tlien  shortly  after  the  canula,  which  contained  meconium. 
There  was  no  longer  any  doubt ;  the  rectum  lay  about  one 
incli  and  three  quarters  in  depth.  A  stylet  was  introduced 
through  the  opening  made  by  the  trocar,  then  upon  the  stylet 
a  hollow  sound,  and  finally  M.  Maissonneuve  used  this  last  as 
a  conductor  to  plunge  into  the  intestine  the  slender  blade  of  a 
Itistoury.  A  flow  of  meconium  immediately  followed.  He 
inti-(xluced  his   finger  into   the   wound  and  thought  he  felt 


THE   THIRD  SPECIES   OF   MALFORMATION.  135 

sonietliiiit!;  auuloij^oiif^  to  a  spliiiictor.  'No  dressiiii,^  of  tlio 
■svoinul  was  made;  only  frequent  lotions  and  the  utmost  clean- 
liness were  advised. 

On  visitinij;  the  child  next  day,  it  was  found  to  have  passed 
a  ii'reat  (pnintity  of  meconium ;  the  na])lvins  were  also  much 
stained  with  blood.  The  child,  however,  had  been  ti'aiupiil 
all  nii;-ht,  had  slept  and  did  not  seem  weakened;  no  more 
blood'^passed  from  the  wound.  On  the  following  days  the 
child  did  not  seem  to  suft'er,  cried  no  more  than  children  or- 
dinarily do,  sucked  with  avidity,  and  grew  fat  sensibly. 
Gradually  the  stools  acquired  the  yellow  color  usual  at  this 
age,  and  when  three  months  old,  the  child  was  in  perfect 
liealth. — {Gazette  des  Ilopltaux  de  Paris.  Fevrier  21, 
Annee  l!S57.     From  La  France  2Iedicale.) 

Case  XXXVIII. — The  following  case  is  reported  by  M. 
Foro-et.  A  child  of  the  female  sex,  thirty-six  hours  old,  and 
not  voiding  the  meconium,  in  spite  of  the  existence  of  an  anus, 
apparently  well  formed,  Avas  submitted  to  my  examination. 
On  the  spot  occupied  by  the  abnormal  anus  w^as  observed  a 
cavity  surrounded  by  diverging  folds  which  all  met  towards 
its  base ;  this  cavity  entirely  formed  by  the  skin,  terminated 
in  a  true  cul-de-sac.  On  widely  separating  the  nates,  the 
folds  which  surrounded  and  in  part  formed  this  cavity  were 
effaced,  and  its  base  was  observed  to  become  depressed  and  to 
be  stretched  transversely  on  the  slightest  effort  of  the  child. 
The  examination  by  the  finger,  practised  whilst  contraction 
was  taking  place,  transmitted  the  sensation  of  a  firm  and  toler- 
ably resisiting  surface,  and  not  at  all  that  of  fluctuation.  Tlie 
child  was  in  other  respects  well  formed.  Tlie  genito-nrinary 
oro-ans  were  in  the  natural  state.  The  urine  was  passed  with- 
out admixture  of  meconium.  No  vomitting  had  taken  place. 
The  exploration  of  the  anus  with  a  small  trocar  did  not  give 
issue  to  any  excremental  liquid.  The  child  died  eight  days 
afterwards. — {Union  Med icale.     Paris.     1850.) 

Case  XXXIX. — ^Tlie  following,  a  somewhat  similar  case  to 
M.  Forget's,  was  read  before  the  "-Boston  Society  for  Medical 
Lnpromment^  by  C.  G.  Page,  M.  D.,  on  the  12th  October, 
1857.  Tlie  infant  was  a  patient  of  Dr.  F,  Higginson  of  Brattle- 
boro,  Vermont. 

"  Tlie  child,  a  female,  apparently  perfect  in  form,  was  born 
Mav  2d,  1855.  The  anus  presented  a  wrinkled  depression  re- 
senibling  the  umbilical  pit,  but  w^as  lined  with  true  skin ;  there 
was  no  appearance  of  mucous  membrane.  An  attempt  to  re- 
lieve by  operative  interference  was  made  first  with  the  tr  "car, 


13G  IHK    TIIIKD    SPECIKS    OF    MALFOEMAllON. 

and  afterwards  with  the  knife,  but  without  result.     The  cliild 
hved  eighteen  days.     At  the  autopsy  the  following  appearan- 
ces were  observed.     The  intestines  were  distended  with  Hatus. 
The  bladder  contained  a  small  quantity  of  dark-colored  urine. 
It  was  drawn  up  out  of  the  j)elvis  and  lay  almost  entirely  over 
the  symphisis  pubis,  the  urethra  making  quite  a  sharp  curve 
under  the  pubic  arch.     The  uterus  was  drawni  from  its  normal 
position  and  rested  on  the  posterior  wall  of  the  bladder,  the 
whole  space  at  the  brim  of  the  pelvis  being  occupied  by  the 
iuHated  rectum.     This  portion  of  intestine  teianinated  in  a  cul- 
de-sac  at  a  point  just  above  the  levator  ani  muscle,  where  the 
peritonaeum  is  reflected  over  from  the  posterior  wall  of  the 
uterus.     At  the  lowest  part  of  this  cul-de-sac   was  an  ecchy- 
mosis,  a  few  lines  in  length,  where  the  muscular  coat  seemed 
to  have  been  divided  ;  the  wound  did  not  extend  into  the  tnu- 
cou^  mcwhranc.     Tlie  bottom  of  the  sac  was  about  on  a  level 
with  the  brim  of  the  pelvis,  having  apparently  been  drawn  up 
by  the  excessive  distention,   and  carrying   with  it   the  other 
pelvic  organs." — {Boston  Medical  and  Surgical  Journal.  Vol. 
L  YII.  p.  238.  Boston  :  1857.) 

Case  XL. — The  follovtring  case  was  communicated  to  the 
"  Boston  Medical  and  Surgical  Journal,^''  on  the  29th  of  De- 
cember, 1857,  b}^  P.  Pineo,  M.  D.,  of  Queechy,  Vt, 

"  A  case  of  imperforate  anus  and  rectum  came  under  my 
observation  last  year,  in  this  place,  in  consultation.  A 
slightly  wi-inkled  depression  was  perceptible  where  the  anus 
should  be,  and,  on  straining,  the  distended  bowel  could  be 
felt  pushing  downward.  An  incision  was  made,  and  the  rec- 
tum reached,  within  about  an  inch  of  tlie  external  opening. 
A  gum-elastic  tube  was  introduced,  and  free  fsecal  discharges 
obtained.  The  child  died  when  about  a  week  old.  No  au- 
topsv."  {Boston  Medical  and  Surgical  Journal.  Vol.  L  VII. 
p.  281.     Boston :    1858.) 

Cask  XLI. — M.  Baron  exhibited  to  the  "  Academic  Royale 
de  Medecine,"  in  November,  1835,  tlie  urinary  defecating 
orgatis  of  a  young  male  child,  born  without  an  anus. 

In  this  case  M.  Veipeau  had  been  called  in.  He  incised  at 
the  place  where  the  anus  should  have  been,  in  the  direction 
of  the  rectum,  until  he  reached  a  cavity,  from  which  he 
thought  he  saw  meconium  to  flow.  Bad  symptoms,  however, 
soon  followed,  and  the  child  died. 

At  the  autopsy  the  cul-de-sac  of  the  rectum  was  found  to 
be  arrested  about  the  level  of  the  fundus  of  the  bladder,  but 
having  no  communication  with  that  organ.     The  bladder  was 


THE   THIRD   SPECIES   OF   MALFOliMATION.  137 

found  to  lill  the  whole  pelvic  cavity,  and  was,  by  tliis  distin- 
guished sui^i^eon,  unavoidably  injured  in  the  operation.  {Re- 
vue Mtdicale  de  l*arls.     Deeeml/re,  1835.    ^j>.  418.) 

Cask  XLII. — M.  Aninssat  relates  the  following  case  of  a 
female  inlant,  in  whom  the  rectum  terminated  in  a  cul-de-sac, 
about  two  inches  above  an  apparently  normal  anus.  In  the 
canal  just  below  the  blind  sac  of  the  rectum,  a  conununica- 
tion  existed  with  the  vagina.  This  exceedingly  complex  and 
difficult  case  was  treated  with  com})lete  success,  and  is  highly 
interesting  on  account  of  its  being  the  first  case  upon  which 
M.  Ainussat  practiced  his  i)eculiar  method.  This  case,  at  lirst 
view,  might  seem  to  belong  to  my  fourth,  or  my  sixth  species. 
In  reality,  however,  it  does  not  belong  to  either,  but  to  the 
third,  in  which  I  have  classed  it.  It  will  be  observed  that 
the  rectum  terminated  in  a  blind  sac,  and  had  no  communi- 
cation whatever  with  the  genito-urinary  organs,  nor  with  the 
apparently  well  formed  anus.  The  anus  communicated  and 
was  confounded  with  the  vulva,  being  nothing  more  than  a 
sujDerlluous  opening.     [  Vide  Plate  V.] 

"  On  the  8th  of  September,  1835,  I  was  summoned  about 
midnight  by  an  English  lady,  sent  to  me  by  my  friend,  Dr. 
Dubreuil.  She  handed  me  a  letter  from  M.  Deneux,  addressed 
to  M.  Blandin,  who  happened  not  to  be  at  home.  h\  this 
letter  M.  Deneux  said, '  the  case  is  one  of  occlusion  of  the  large 
iiitesii/ies,  in  a  new-horn  i/fant,  the  anus  is  lo  ell  formed  ',  the 
rectum  communicates  with  the  vagina,  and  the  obstruction 
seems  to  he  high  up.'' 

"  I  arrived  at  tlie  house  of  M.  B***,  an  Englishman,  situa- 
ted at  the  Rond-Point  des  Champs-Elysees,  about  one  or  two 
o'clock  in  the  morning.  I  there  met  M.  Deneux,  who  had 
delivered  Madam  B.  He  informed  me  that  the  child  was 
born  on  the  6th  of  September,  at  four  o'clock,  p.  m.,  and  was 
consequently  now  thirty-three  or  thirty-four  hours  old ;  that 
no  meconium  had  yet  passed. 

"The  nurse  told  us  that  tepid  Tvater  injected  by  the  anus 
passed  out  by  the  vulva.  She  also  assured  us  that  she  had 
found  the  diapers  quite  wet  with  urine.  This  seemed  doubtful 
to  us. 

"This  first  child  by  a  second  marriage,  although  born  at 
seven  months,  seemed  to  be  lively  and  of  a  vigorous  constitu- 
tion ;  the  abdomen  was,  however,  hard  and  distended ;  the 
anus  and  vulva  were  well  formed.  A  flexible  canula  intro- 
duced by  the  anus,  readily  penetrated  about  two  inches,  and 
v/ater  injected  through  it  came  out  immediately  by  the  vulva. 


138  THE   THIED    SPECIES    OF   MALFORMATION. 

A  sontid  passed  by  the  vulva  into  the  vagina  readily  met  the 
canuhi  previously  introduced  into  the  anus. 

"  We  thought  that  the  rectum  was  obstructed  at  the  height 
of  about  two  inches,  and  that  it  communicated  with  the  va- 
gina; that  is  to  say,  we  thought  we  recognized  a  recto-vaginal 
Jidida,  or  in  other  words,  that  the  septum  by  which  the  rec- 
tum and  vagina  are  parted,  was  deficient  to  a  considerable 
extent. 

"During  the  examination  of  the  parts,  which  was  continued 
some  time,  the  nurse  dipped  her  little  linger  in  sweetened 
water,  and  gave  it  to  the  child  to  suck.  After  having  once 
more  carefully  determined  tlie  state  of  the  case  as  above 
given,  our  first  care  was  to  inform  the  parents  of  our  conclu- 
sion. They  understood  from  us  that  there  were  but  two  ways 
of  aflbrding  issue  to  the  meconium ;  viz — first  by  the  anus,  or 
the  natural  passage ;  second  by  the  abdomen. 

"  We  readily  made  them  comprehend  the  danger  of  either 
method  of  operation,  as  well  as  the  inconveniences  attending 
them ;  and  we  added,  that  in  case  we  succeeded  in  reaching 
the  rectum  by  the  vagina,  there  would  necessarily  be  a  com- 
munication between  the  intestine  and  the  vagina.  Notwith- 
standing this,  the  parents  immediately  rejected  the  idea  of  an 
operation  after  the  method  of  Littre,  and  coincided  with  us  in 
thinking  it  far  better  to  attempt  to  reestablish  the  natural 
anus,  even  with  the  inconvenience  of  a  fistula,  than  to  form  a 
new  one  in  the  abdomen. 

"  It  was  then  determined  that  we  should  pursue  the  search 
for  the  obstructed  rectum.  With  this  view  I  proposed  dila- 
ting the  anus  with  prepared  sponge.  At  four  o'clock,  a.  m.,  a 
piece  of  this  sponge  about  an  inch  and  a  half  long,  but  some- 
what smaller  than  the  little  finger,  with  a  thread  attached  to 
one  end,  was  introduced  into  the  anus,  and  kept  in  place  by  a 
compress  and  a  T  bandage.  It  was  agreed  that  I  should  re- 
turn about  eight  o'clock  in  the  morning,  to  replace  this  with 
a  longer  and  thicker  piece,  and  that  we  would  meet  again  at 
noon  and  perform  an  operation,  if  one  were  necessary. 

"At  eight  o'clock  I  withdrew  the  sponge,  moist  and  swol- 
len ;  the  anus  was  considerably  dilated.  I  could  introduce 
my  little  finger,  which  was  easily  seen  by  the  vulva,  but  I 
was  stopped  higher  up  by  a  cul-de-sac.  As  it  was  doubtful 
whether  the  child  had  urinated,  I  sought  for  the  urethra  Avith 
a  small,  strait  silver  sound,  without,  however,  discovering  the 
passage.  The  little  girl,  however,  urinated  abundantly  dur- 
ing my  search,  owing  no  doubt  to  the  titillation  of  the  meatus 
urinarius  with  my  sound.     A  new  sponge,  a  little  thicker  and 


THE   TIIIKD    SPECIES   OF   MALFORMATION.  139 

longer  tlian  the  first,  was  introduced  int<j  tlie  anus,  wliere  it 
was  retained  as  already  described. 

"  At  noon,  according  to  agreement,  M.  Denenx  returned 
with  me  to  deliberate  upon  the  course  to  be  pursued.  I  in- 
troduced M.  Lebaudy  to  tlie  consultation,  who  had  expressed 
n  desire  to  assist. 

"After  removing  the  sponge  which  had  yet  more  dilated 
the  anus,  I  introduced  my  little  finger  as  deeply  as  possible 
by  this  opening,  without  recognizing  anything  besides  the 
cul-de-sac  already  spoken  of.  1  again  easily  caused  the  end 
of  my  little  finder  to  appear  in  the  vulva.  Messieurs  Deneux 
and  Lebaudy  also  did  the  same. 

"  We  then  endeavored  to  discover  the  rectum,  distended 
with  meconium,  with  the  intention  of  puncturing  it. 

"  The  parents  were  informed  that  in  the  latter  case  there 
would  necessarily  be  a  recto-vaginal  fistula.  Not  satisfied 
with  our  exploration,  although  the  child  was  already  quite 
fatigued,  I  determined  to  introduce  the  right  fore-finger  into 
the  anus.  In  this  new  examination,  both  above  and  behind, 
I  found  only  a  soft  pouch,  wdiich  I  thought  must  be  formed 
by  the  rectum.  However,  above  and  in  front  of  the  cul-de- 
sac  which  arrested  my  finger,  I  discovered  a  species  of  fun- 
goid contraction,  which  I  at  first  took  for  the  contracted  or 
obturated  point  of  the  intestine. 

In  explanation  of  what  I  had  discovered  I  remarked  to  M. 
M.  Deneux  and  Lebaudy  that  the  body  which  I  had  touched 
produced  the  same  sensation  that  would  be  produced  by  the 
effaced  and  soft  neck  of  the  uterus,  and  the  opening  of  which 
was  very  narrow.  Each  of  these  gentlemen,  on  examination, 
recognized  the  same  sensations,  and  M.  Deneux  told  us  that 
it  must  be  the  neck  of  the  uterus  of  the  little  girl.  A  new 
examination  was  made  confirming  the  opinion  of  M.  Deneux. 
It  was  then  established  that  a  vagina  existed,  into  wdiich  the 
anus  opened  without  a  rectum,  and  that  the  vulva  and  the 
anus  communicated  with  the  vagina ;  there  were  also  by  a 
strange  anomaly,  two  openings  in  the  perinEeum  in  place  of 
one,  and  both  terminated  in  the  vagrina. 

After  assuring  ourselves  that  we  had  to  do  with  an  extra- 
ordinary malformation,  consisting  of  the  absence  of  the  rectum, 
or  a  part  thereof,  I  resolved  to  carefully  explore  the  entire 
pelvic  cavity,  through  the  walls  of  the  vagina,  at  the  same 
time  introducing  the  fore-finger  by  the  anus,  or  second  open- 
ing of  the  vagina,  with  the  intention  of  seeking  for  the 
wanting  intestine.  After  having  thoroughly  explored  the 
long  walls  of  the  pelvis  in  front  and  rear  and  on  the  sides,  I 
recognized  with  some  difficulty  in  front,  the  bladder,  in  the 


140  TIIK   THIRD    SPECIES    OF   MALFORMATION. 

rear  the  sacrum  and  the  sacro-vertebral  angle  which  I  care- 
fully examined.  I  sought  for  tlie  pouch  which  should  be 
formed  by  the  rectum  distended  with  meconium ;  feeling 
towards  the  left  of  the  sacro-vertebral  angle  with  the  end  of 
the  finger  across  the  posterior  wall  of  the  vagina,  I  felt  a 
flattened  body  which  escaped  from  the  finger  when  it  pressed 
a  certain  distance.  I  repeated  the  experiment  several  times, 
and  always  wntli  the  same  result.  Reflecting  on  this  fact,  I 
concluded  the  object  which  I  touched  must  be  the  rectum. 
I  communicated  my  discovery  to  my  associates  who  coincided 
with  me  in  opinion  after  making  the  same  examination. 

At  once  the  diagnosis  hitherto  so  difficult,  became  more 
clear  and  certain  with  relation  to  the  facts  already  established, 
namely,  that  tlie  vagina,  larger  than  ordinary,  appeared 
alone  to  occupy  the  pelvic  cavity,  and  that  above  and 
behind,  at  tlie  left  of  the  sacro-vertebral  angle  was  placed  the 
extremity  of  the  imperforate  rectum. 

I  now  felt  quite  relieved  and  freed  from  the  difiiculty 
presented  by  an  operation  so  delicate,  and  I  immediately 
resolved  to  put  into  practice  the  method  I  had  long  since 
devised  for  similar  cases  of  absence  of  the  rectum. 

I  described  the  process  which  I  proposed  adopting  in  this 
case,  and  w^hich  was  as  follows :  to  make  an  opening  in  front 
of  the  coccyx  and  behind  the  vaginal  anus,  detaching  with  the 
finger  and  the  bistoury  the  posterior  wall  of  the  vagina  from 
the  coccyx  and  the  sacrum  ;  to  penetrate  as  far  as  the  cul-de- 
sac  of  the  large  intestine,  recognizing  it  both  by  the  vagina  and 
by  the  natural  passage ;  to  seize  it  with  the  tenaculum  ;  to 
free  its  attachments  rather  with,  the  finger  than  with  the 
bistoury,  to  bring  it  down  to  the  opening  of  the  skin  ;  to 
open  it  thoroughly,  allow  the  meconium  to  pass  off,  and  then 
to  fasten  in  a  proper  manner  by  interrupted  sutures,  the 
opening  of  the  intestine  to  that  of  the  skin. 

Examination  was  again  made  ;  the  diagnosis  and  indica- 
tions seemed  then  so  clear  that  they  thought  since  the  last 
examination  that  everything  was  wonderfully  favorable  to 
the  bold  operation  which  I  had  proposed.  From  this  moment, 
being  perfectly  agreed,  the  operation  was  decided  upon  and 
the  chances  were  laid  before  the  parents,  who  comprehending 
the  unfortunate  condition  of  their  child,  were  resigned  to 
whatever  })lan  we  judged  best  to  adopt.  We  did  not  conceal 
from  them  the  dangers  of  such  an  operation.  They  were, 
however,  informed  in  opposition  to  what  we  had  heretofore 
told  them,  that  if  we  now  succeeded  in  effecting  an  evacua- 
tion of  the  meconium,  not  only  would  we  save  the  child,  but 
there  would  be  no  recto-vaginal  fistula. 


TIIK   THIRD   SPECIES   OF   MALFOKMATION.  141 

"During  all  this  time  tlic  cliiM  had  been  placed  in  an 
emollient  bath,  to  calm  the  irritation  caused  by  such  a 
todions  and  ])aint"nl  but  unavoidable  examination, 

"  Everything  being  prcpare<l  a  new  examination  relative  to 
the  ])ertbrmance  of  the  operation  having  been  made,  and  the 
child  being  placed  upon  the  table,  as  if  to  be  dissected,  I 
made  a  transverse  incision  with  a  short  and  round  edged 
bistoury,  six  or  eight  lines  in  extent  behind  the  vaginal  anus ; 
another  incision  towards  the  coccyx  gave  the  form  of  a  T  to 
the  opening  by  wliicli  my  linger  was  introduced,  to  make  a 
passage  between  the  vagina,  on  the  one  liand,  and  the  coccyx 
and  sacrum  on  the  otlier ;  having  previously  placed  a  sound 
in  the  vaginal  anus  to  serve  as  a  guide  to  protect  its  posterior 
wall  from  injury,  I  partly  tore  and  partly  cut  the  cellular 
tissue  uniting  these  parts.  Thus  I  penetrated  at  least  tAvo 
inches  >'nd  found  the  extremity  of  the  rectum.  At  the 
moment  the  child  made  an  instinctive  effort,  I  was  enabled 
to  recognize  the  termination  of  the  rectum  much  better  than 
I  hitherto  had  done  by  the  vagina.  The  end  of  the  intestine 
was  pouch-like.  My  associates  were  as  much  delighted  as 
myself  upon  recognizing  this  condition  of  the  parts. 

"  I  then  decided  to  seize  this  pouch  with  a  double  tenaculum  ; 
drawing  it  towards  me.  I  separated  the  intestine  from  the 
slight  adhesions  which  it  had  to  the  surrounding  parts,  except 
on  the  side  of  the  vagina,  where  I  was  obliged  to  use  the 
bistoury  with  much  caution.  By  this  means  the  traction  Avas 
so  much  facilitated  that  we  soon  perceived  the  intestinal 
pouch  at  the  bottom  of  the  wound,  and  with  great  satisfaction 
recognized  the  meconium  oozing  out  by  the  side  of  the  hooks 
of  the  tenaculum.  I  then  transfixed  the  cul-de-sac  of  the 
rectum  with  a  needle  armed  with  a  double  ligature,  and  by 
the  aid  of  this  and  the  tenaculum  the  intestine  was  brought 
down  to  the  surface  of  the  wound  in  the  skin.  A  sufficiently 
large  opening  having  been  made  between  the  ligature  and 
the  tenaculum,  a  great  quantity  of  gas  and  meconium  imme- 
diately gushed  out.  After  cleaning  the  child,  who  was  much 
relieved  by  this  evacuation,  I  terminated  the  operation  in 
the  following  manner  :  — 

"  Having  assured  myself  that  the  intestinal  opening  was 
sufficient,  I  seized  witli  bull-dog  forceps,  the  edges  of  the 
opening,  I  placed  these  forceps  in  the  hands  of  assistants  who 
were  to  make  continued  traction  upon  the  intestine  until  the 
part  seized  upon  should  extend  beyond  the  opening  made  in 
the  skin.  I  then  made  three  points  of  suture  at  each  angle 
of  the  wound  ;  but  I  noticed  that  the  traction  exerted  upon 
the  intestine  made  it  ascend,  and  that  it  was  no  longer  even 


142  THE   TIITRD   SPECIES    OF   MALFORMATION. 

with  the  skin.  I  then  made  with  more  care  six  or  eight 
points  of  suture  in  the  circumference  of  the  intestine,  the 
mucous  membrane  I  spread  outside  in  the  form  of  the  mouth 
of  a  trumpet.  [  Vide  Plate  V.  Figures.  1,2,3.]  During  the 
whole  operation  but  little  blood  was  lost.  Injections  into  the 
new  rectum  were  made  immediately  afterwards,  and  the 
child  was  placed  in  a  hip  bath.  The  linen  of  the  child  was 
changed  five  or  six  times  in  two  or  three  hours  after  the 
operation,  and  the  meconium  was  always  found  mixed  with 
a  marked  quantity  of  blood  which  seemed  to  ooze  out  from 
the  left  angle  of  the  wound.  Several  injections  were  made 
both  in  the  artificial  and  vaginal  anus.  Poultices  of  flax-seed 
meal  were  applied  to  the  wound.  During  all  this  time  the 
little  patient  seemed  to  grow  w^eaker.  She  grew  pale  and 
her  extremities  became  cold.  Hitherto  she  had  been  left  in 
her  cradle ;  she  was  now  placed  by  the  side  of  her  mother  in 
bed,  who  restored  her  to  warmth  and  vigor  in  a  short  time. 
From  seven  to  eleven  o'clock  at  night  she  was  cleansed  several 
times,  and  she  took  a  bath  of  ten  minutes.  At  each  cleansing 
the  quantity  of  meconium  and  blood  diminished.  The  breast 
was  frequently  oflfered  to  her,  at  first  without  efi:ect;  but  she 
soon  sucked  strongly  and  finally  went  to  sleep.  There  was 
no  appearance  of  fever,  and  twelve  hours  after  the  operation 
there  was  no  disturbance  at  tlie  points  of  suture.  The 
wounded  parts  preserved  their  redness,  but  the  inflammation 
made  no  great  progress. 

"  On  the  9th  of  September,  at  eleven  o'clock,  A.  M.,  a  con- 
sultation was  had  with  the  following  results  :  First,  the  gene- 
ral health  of  the  child  w^as  satisfactory — second,  the  excretion 
of  fffical  matter  was  perfectly  well  made — third,  there  was  no 
ie,YQ,r— fourth,  the  swelling  around  the  circumference  of  the 
vaginal  anus  had  considerably  abated — -fifth,  the  inflammatory 
redness  which  surrounded  this  part,  as  well  as  the  surgical 
anus,  had  lost  much  of  its  intensity — sixth,  the  points  of  suture 
being  well  sustained,  everything  conduced  to  make  us  think 
the  operation  entirely  successful. 

"  On  the  11th  of  September,  the  wound  and  the  surround- 
ing parts  were  found  to  be  in  a  satisfactory  condition.  The 
functions  of  nutrition  and  excretion  were  satisfactorily  accom- 
plished ;  in  a  word,  the  child  appeared  as  well  as  if  she  had 
been  born  without  anv  deformity."  {Gazette  JSLedicale  dc 
Paris.  Nov.  28,  1835— A^o.  XL  VIII.  p.  753.) 

The  success  of  the  operation  in  the  preceding  case  was  com- 
plete, for  the  patient  was  reported  as  being  in  excellent  health 
upwards  of  eight  years  after.  {Gazette  Mtdieale  de  Paris. 
1843.  p.  100.     Gazette  des  Hopitaux  de  Paris.  1843.  p.  67.) 


THE   TIIIKD    SPECIES    OF   MALFORMATION.  143 

Dr.  Ileriuann  Fricdhcrf^  of  ]>erlin,  in  liis  Essay  on  Artifi- 
cial Anus,  remarks,  tliat  when  lie  visited  Paris  i)i  1854,  ho 
learned  from  M.  Amussat  that  this  very  ^irl  was  then  in 
excellent  health,  and  about  to  be  married.  She  was  nineteen 
years  of  age. 

Case  XLIII. — ^Tlie  following  case  of  imperforation  of  the 
anus  and  rectum  is  reported  by  Mr.  Waters  of  England,  pre- 
viously referred  to,  in  which  a  precisely  similar  operation  was 
performed,  to  that  of  M.  Amussat : 

"  On  the  10th  of  February,  1842,  Mrs.  M was  confined 

of  a  strong  nuile  child.  She  was  attended  by  a  nurse,  wli(» 
did  not  discover  till  the  following  day  that  the  child  had  been 
born  with  imperforate  anus.  I  was  called  in  on  the  lltli. 
The  child  had  had  two  or  three  doses  of  castor  oil  before  the 
malformation  was  discovered.  I  found  it  suffering  intensely. 
The  abdomen  tense  and  painful  on  pressure  ;  no  vomiting. 
Tlie  central  raphe  of  the  periiifeum  w^as  well  marked,  but 
there  was  not  the  slightest  trace  of  an  anus.  Pressure  over  the 
abdomen  did  not  produce  any  tension  or  fullness  in  perineo. 

"  As  there  w^as  not  any  time  to  lose,  I  emptied  the  bladder, 
and  made  a  free  incision  into  the  central  line  of  the  pe- 
ri]in3um,  and  carried  the  wound  upwards  and  backwards 
above  an  inch  without  discovering  any  trace  of  the  intestine. 
I  then  had  recourse  to  a  bistoury,  and  succeeded  in  finding 
the  extremitv  of  the  rectum,  terminatino-  in  a  distinct  cul-de- 
sac,  opposite  the  promontory  of  the  sacrum,  filled  with  hard- 
ened meconium,  which  I  had  some  difliculty  in  dislodging. 
I  got  hold  of  the  edges  of  the  intestine  which  I  gradually 
hrouglit  down.,  and  united  to  the  edges  of  the  integuments  by 
four  points  of  suture  ;  I  did  this  with  the  idea  of  presenting  a 
continuous  mucous  surface  to  the  passage  of  fseces,  and  so 
prevent  irritation  of  the  Avound,  and  also,  if  possible,  to  ijre- 
vent  adhesion  by  presenting  two  mucous  surfaces  to  each 
other.  The  bowels  were  freely  acted  on  immediately  after 
the  operation,  and  the  abdomen  fomented  until  pain,  (fee.  were 
removed. 

"  The  sutures  were  removed  on  the  third  day,  and  every 
thing  progressed  favorably  until  about  ten  days  since,  wdien 
the  wound  commenced  to  contract  rapidly.  I  counteracted 
this  by  the  regular  introduction  of  a  large  bougie,  and  occa- 
sionally pieces  of  prepared  sponge.  The  contraction  only 
exists  at  the  surface,  the  remainder  of  the  passage  is  lined  by 
the  intestine,  and.  does  not  appear  disposed  to  narrow  its 
calibre. 

"  April  Yth.     Mr.  "Waters  writes,  I  may  add  that  the  case 


li-i  THE    THIRD    SPECIES    OF   MALFORMATION. 

is  going  on  most  favorably.  The  child's  general  health  is 
very  good,  and  there  is  not  any  difficulty  experienced  in 
keeping  the  opening  in  the  integuments  sufficiently  dilated. 
The  tendency  to  contract  only  exists  in  the  mere  integu- 
ments, above  this  the  intestine  preserves  its  natural  size." 
{The  Diiblhi  Journal  of  Medical  Science.  Vol.  XXI.  p. 
321.  lSi2.) 

Case  XLIV. — ^The  following  highly  interesting  case  was 
reported  by  W.  G.  Smith,  M.D.,  of  Vauxhall-Walk,  London, 
April,  1846.  It  will  be  seen  that  the  case  w^as  a  desperate 
one,  the  end  of  the  rectum  having  been  found  about  three 
inches  from  the  surface,  but  evidently  without  adliesions, 
floating ;  or  it  could  not  have  been  brought  down  so  easily. 
The  operation  was  skilfully  performed,  and  cro^vTied  with 
comj^lete  success,  the  rectum  having  been  brought  down  in 
the  manner  directed  by  M.  Amussat,  but  not  attached  by 
sutures. 

"  A  male  infant,  born  at  ]^o.  45,  Catharine-Street,  Lambeth, 
had  been  in  the  world  for  two  days  before  the  parties  attend- 
ing it  discovered  the  malformation  described  below.  The 
child  had  refused  the  breast — had  been  vomiting  and  liiccup- 
ing ;  the  abdomen  w^as  swollen  and  hard.  It  was  obvious 
that  the  rectum  lay  deep,  there  being  no  indication,  either  by 
color  or  touch,  of  its  situation,  or  of  any  external  preparation 
for  an  anus.  My  friend,  Mr.  Smyth,  of  Lambeth-walk,  agreeing 
with  me  that  this  was  not  a  case  to  admit  of  a  moment's  delay, 
with  his  assistance  I  proceeded  to  search  for  the  rectum,  the 
child  being  placed  on  the  midwife's  knee,  on  its  belly,  being 
less  likely  to  kick  or  to  be  troublesome  in  that  position. 
Making  an  incision  in  the  middle  of  the  perinseum,  the 
sphincter  was  observed  to  be  straight,  its  inner  sides  being  in 
close  contact.  This  was  cut  through,  and  part  of  the  levator 
ani  and  the  fatty  matter  beneath  were  divided  to  the  depth 
of  an  inch ;  but  I  could  find  no  indication  of  where  the  rec- 
tum lav.  I  enlarged  the  external  wound  in  both  directions, 
and  then  continued  to  cut  cautiously  upwards  and  back- 
wards ;  and  having  arrived  at  the  depth  of  about  three 
inches — being  able  to  touch  the  pubes  in  front  and  the  sacrum 
behind,  the  wound  being  large  enough  to  bury  the  index  fin- 
ger— on  examining  with  great  care,  we  could  not  discover 
any  appearance  of  a  rectun"i.  However,  when  the  child  cried, 
a  slight  impetus  was  felt — a  descending  from  behind — towards 
which,  through  the  intervening  substance,  I  pushed  a  trocar, 
as  slender  as  an  exploring  needle ;  and  on  the  second  applica- 
tion, the  escape  of  gas  through  the  caimla  satisfied  us  that  the 


THE  TIIIKD  8PECIE3   OF   MALFORMATION.  145 

howel  had  boon  vcacliod.  T  made  an  nttoinpt  to  onlari^^o  the 
opeuiiii^  with  a^ director  and  a  bistoury,  but  found  there  was 
no  room  to  act  with  certaintj.  A  full-sized  trocar  I  easily 
introduced  ;  and  by  pressing  on  the  bowels,  a  considerable 
quantity  of  meconium  was  expelled  ;  a  bougie  Avas  then  left 
in  the  wound.  On  the  next  day,  a  probe  was  passed,  along 
which  the  canula  was  easily  guided  into  the  bowel,  which  it 
reached  when  pressed  into  the  external  wound ;  but  it  was 
only  by  squeezing  the  bowels  that  the  contents  could  be  made 
to  flow  outwardly. 

"  It  was  quite  evident  how  difHcult,  if  not  impossible,  it 
would  be  to  make  an  efficient  opening  for  the  faeces  to  pass 
through  this  lono;  and  rather  curved  channel :  and  how  diffi- 
cult  it  would  be  to  prevent  such  an  opening  from  closing ; 
and  also  how  unlikely  the  power  of  either  voluntarily  expelling 
or  retaining  the  faeces  would  be  obtained.  I  therefore  con- 
sidered it  expedient  to  bring  the  bowel  down  into  the  wound  ; 
for  this  purpose,  I  passed  a  small  pair  of  case-forceps  along 
the  canula,  and  laying  hold  as  near  the  opening  into  the  bowel 
as  I  could  reach,  I  gently  and  gradually  pulled  it  down  upon 
the  canula.  This  being  repeated  tw^o  or  three  times,  the 
opening  into  the  bowel  was  brought  down  to  near  the  mouth 
of  the  external  wound.  No  means  were  used  to  retain  it,  and 
the  injection  of  warm  water  now  thrown  np  was  returned 
with  power.  The  canula  remained  in  the  bowel  for  ten  days, 
the  foeces  being  freely  expelled  through  it  by  the  muscles  of 
the  rectum.  The  greater  portion  of  the  wound  healed  by  the 
iirst  intention  around  the  canula  by  granulations.  The 
sphincter  now  acts  well,  and  a  good  anus  is  formed — if  ^any- 
thing, a  little  too  far  back ;  the  bowels  act  naturally,  a  bougie 
being  occasionally  passed.  A  month  has  elapsed,  and  no  bad 
svmptom  has  occurred."  [London  Lancet.  Vol.  LV.  p.  125. 
1846.) 

Casks  XLV. — XLYI. — Tlie  two  following  interesting  cases 
of  imperforation  of  the  anus  and  rectum  are  reported  by  M. 
Amnssat.  In  these  cases  he  established  the  artificial  anus  in 
the  coccygeal  region,  but  unfortunately  each  case  terminated 
fatally  in  a  few  days. 

Llrst  Case. — "At  seven  o'clock,  A.  M.,  on  the  15th  day  of 
May,  1842,  Dr.  Garnier,  physician  at  Charonne,  sent  me  a 
male  infant  twenty-four  hours  old.  The  child  had  passed  no 
meconium  ;  its  abdomen  was  hard  and  distended,  and  it  vom- 
ited several  times.  I  examined  it  attentively  and  observed 
that  the  raphe  existed,  and  at  the  point  where  the  anus  should 
have  opened  there  was  an  ovoid  tumor  or  rather  a  longitudinal 
crest,  several  lines  in  length.  In  fine,  the  space  contained  be- 
10 


14:G  THE  THIRD  SPECIES   OF   MALFOKMATION. 

twecn  the  tuberosities  of  the  ischium,  on  the  one  hand,  and 
between  the  scrotum  and  the  coccyx  on  the  other,  seemed  to 
me  distended,  and  I  perceived  a  very  sensible  fluctuation  in 
tliis  region.  I  will  also  add  that  on  pressing  the  tumor  placed 
at  the  point  where  the  anal  opening  should  have  existed,  1 
thought  I  perceived  a  depression  apparently  bounded  by  the 
two  halves  of  this  sphincter.  The  same  sensation  of  fluctua- 
tion was  also  perceived  when  during  expiration  the  left  hand 
was  laid  on  the  abdomen,  whilst  pressure  with  the  right  was 
made  in  the  peringeum.  Having  made  these  facts  clearly  evi 
dent  to  all  the  assistants,  I  had  an  almost  perfect  conviction 
that  the  rectum,  distended  w^ith  meconium,  terminated  at  no 
great  distance  from  the  skin. 

"  Tlie  child  being  then  placed  on  a  table  suitably  arranged 
for  operation  on  the  sub-pubic  region,  I  explored  anew  the 
jjerinseal  region,  whilst  M.  Boyer  pressed  upon  the  abdomen, 
and  at  the  point  where  I  perceived  a  sufficiently  manifest  fluc- 
tuation, and  near  the  median  tumor  already  spoken  of,  I  forc- 
ibly plunged  the  blade  of  a  bistoury  from  above  downwards, 
and  from  front  to  rear.  This  deep  incision  gave  vent  to  no 
matter,  to  my  great  astonishment,  making  me  fear  an  error  in 
the  diagnosis  1  had  made.  But  on  enlarging  the  opening  just 
made,  towards  the  front,  when  I  withdrew  my  instrument  a 
black  glutinous  meconium  flowed  out.  I  now  introduced  a  di- 
rector, and  passed  a  bistoury  on  it,  and  enlarged  the  opening 
towards  the  rear.  After  this  incission  the  meconium  flowed 
abundantly. 

"  The  child  was  very  feeble ;  it  was  cold  and  of  a  violet 
hue,  and  breathed  with  difficulty,  perhaps  during  the  opera- 
tion the  head  had  been  left  in  a  too  low  position.  They  raised 
the  head,  agitated  the  chest,  and  presently  the  respiration  be- 
came full  and  the  eyes  moved.  Sleconium  still  continued  to 
flow,  at  flrst  of  a  black  color,  it  became  clearer  and  mixed 
with  gases,  as  if  it  came  from  the  small  intestines.  Some 
streaks  of  blood  were  also  seen  in  the  matter  which  was  passed. 
The  child  was  cleaned  and  placed  near  the  fire  to  w'arm  it, 
and  a  pledget  of  lint  was  inserted  in  the  opening  which  had 
been  made.  Death  supervened  one  or  two  days  after  the  op- 
eration. 

"  The  Autopfty. — It  was  discovered  that  the  rectum,  much 
dilated  throughout  its  full  extent,  and  especially  in  its  lower 
part,  terminated  aljout  one  inch  from  the  artificial  anus  which 
had  been  made,  and  that  it  was  necessary  to  reach  that  depth 
to  touch  it  with  the  instrument.  The  left  lumbar  colon  was, 
as  in  every  other  case  which  I  have  observed,  fixed,  so  to  say, 
to  the  lumbar  wall,  and  free  from  peritonteal  coat  in  the  lower 


THE   THIRD   SPECIK3    OF   MALFORMATION.  147 

tliird,  at  least,  of  its  caliber,  and  circumscriLed  within  by  the 
kitlney  covered  with  the  anterior  fold  of  the  i)erit()nieii:.n. 
The  mesenteric  and  lumbar  ganglions  were  tilled  with  pus. 
Ilie  intestinal  nnicous  membrane  was  red  and  injected  throif'-h 
a  gi-eat  })art  of  its  extent." — {Troisicme  Memo'ire  sur  la  I'os- 
sihil'tte  (Tetahlir  une  ottverture  artijicial  sur  la  Colon  lombaire 
gauche  sans  ouvir  le  Jr'eritoine  chez  les  Enfans  imperfores. 

Lu  a  VAcademie  lioyale des Sciences,  le  4  Julliet^  1842 

Alm^  IJ Examinateur  Medical  de  Paris.  Annie  184:3. 
tome  III.  p.  216.) 

Second  Case. — "  I  was  called  by  M.  le  docteur  Yignola  to 
see  a  female  infant  having  an  imperforate  anus  and  rectum. 
In  this  case  there  was  no  perceptible  fluctuation  in  the  anal, 
perinaeal  and  coccygeal  region.  An  incision  was  made  in 
the  region  of  the  coccyx,  but  not  deep  enough  to  reach  the 
rectum.  In  order  to  penetrate  to  a  still  greater  depth,  a  sec- 
tion of  the  point  of  the  coccyx  was  made,  which  in  this  case 
w^as  very  much  curved. 

"  At  last,  fearing  that  prolonging  the  incision,  some  impor- 
tant organ  might  be  injured  without  finding  the  rectum,  I 
proposed  to  M.  Breschet,  who  assisted  in  the  operation,  to 
establish  an  artificial  anus  in  the  left  lumbar  region.  The  pro- 
position was  submitted  to  the  parents  of  the  child,  but  they 
rejected  it.  The  operation  was  then  continued  in  the  region 
in  which  it  had  been  commenced,  and  the  rectum  was 
found  attached  to  the  upper  part  of  the  vagina.  Some 
meconium  was  evacuated,  then  the  intestine  was  fixed  in  the 
skin  by  two  points  of  twisted  suture.  The  child  died  on 
the  fourth  day,  and  the  parents  were  unwilling  to  allow  a 
post-mortem  examination. 

"  It  is  evident  in  this  case,  that  death  was  caused  by  the 
severe  inflammation  resulting  from  the  very  long  search  neces- 
sarily made  to  discover  the  rectum  distended  with  meconi- 
um."— {Log.  cit.  .) 

Case  XLYII.  The  following  very  interesting  case  of  imper- 
foration  of  the  anus  and  rectum  is  related  by  Dr.  Hermann 
Friedberg  of  Berlin,  already  alluded  to. 

"  Ernest  Adolph  S was  born,  at  full  time,  without  dififi- 

culty,  on  the  31st  of  August  1851,  at  three  o'clock  P.  M.,  (a 
first  confinement.)  In  the  warm  bath  which  was  immediately 
given  the  child,  it  uttered  loud  cries,  and  slept  afterwards  for 
several  hours  ;  towards  evening  it  took  several  spoonfuls  of 
chamomile  tea,  and  slept  tranquilly  till  nearly  midnight.  It 
awoke  with  cries  and  manifested  much  restlessness,  drew  up 


\ 


148  TITE   THEKD    SPECIES    OF   MALFOEMATIOX. 

*"  its  knees  and  tossed  from  side  to  side,  bent  in  its  tlnimbs  and 
passed  urine  frequently.  The  cries  soon  gave  place  to  groans, 
■W'tiich  lasted  until  the  following  day,  M'hilst  the  tossings  con- 
stantly increased.  During  the  afternoon  of  the  first  of  Sep- 
tember, the  child  was  visited  by  the  nurse,  who  thought  it  to 
])e  sufl:ering  from  colic,  and  wished  to  give  it  an  injection. 
Not  finding  any  anus,  I  was  called  to  see  the  child. 

Tlie  following  symptoms  presented  themselves  at  my  an-i- 
val. — The  body  quite  well  formed,  was  in  good  condition ; 
the  extremities  pale  and  cold,  presented  frequent  contractions, 
which,  began  also  to  appear  in  the  muscles  of  the  face,  which 
was  pale  and  cold.  The  pulsation  of  the  heart,  very  feeble, 
could  hardly  be  counted.  The  abdomen  was  unusually  prom- 
inent, and  its  teguments  of  a  bluish  color,  were  warm  and 
very  sensitive  to  percussion,  which  gave  a  tympanitic  sound. 
The  pelvic  cavity  seemed  not  fully  developed  ;  the  sciatic 
tuberosities  were  somewhat  drawn  together,  and  the  point  of 
the  coccyx  was  considerably  bent  forward.  The  perinseal 
region  was  neither  arched  nor  contracted,  and  altogether  had 
the  form  of  a  truncated  cone ;  the  raphe  was  not  strongly 
developed,  and  reached  to  the  coccyx  ;  there  was  no  trace  of 
an  anus.  Two  or  three  lines  in  front  of  the  point  of  the  coc- 
cyx, there  was  an  elevation  about  the  size  of  a  lentil  seed, 
and  of  a  cup-like  form,  which  seemed  to  be  formed  by  the 
skin  and  by  the  hypertrophied  cellular  tissue.  Tlie  hollow 
of  this  excrescence  reached  the  level  of  the  surrounding  skin, 
and  was  lined  with  skin  of  normal  appearance.  This  excre- 
sence  could  be  depressed  without  feeling  any  cord  beneath, 
as  an  evidence  of  communication  with  the  organs  of  the  pel- 
vic cavity.  Tlie  child  continually  groaned  in  a  very  feeble 
and  gentle  manner,  breathed  irregularly,  and  endeavored 
from  time  to  time  to  put  into  action  the  pressure  of  the 
abdominal  muscles.  Besides  the  countenance  had  now 
become  livid ;  in  the  perinjieal  region  there  was  manifest 
pressure  of  the  rectum,  while  the  child  placed  in  the  usual 
bent  position  in  which  children  are  held.  I  did  not  hear 
either  by  the  stethoscope  applied  to  the  peringeum,  or  by  per- 
cussion of  the  anterior  wall  of  the  abdomen,  anv  sound  indi- 
cating the  presence  of  the  rectal  extremity  filleu  with  gas  and 
fsecal  matter.  Several  times  I  pressed  with  the  end  of  my 
left  fore  finger  on  the  perinseum,  towards  the  pelvic  cavity, 
and  at  the  same  time  made  percussion  with  my  right  hand 
upon  the  anterior  wall  of  the  abdomen,  but  without  discover- 
ing any  approach  of  the  rectum  towards  my  fore-finger. 
Although  from  this  fact  as  well  as  the  narrowness  of  the 
pelvic  cavity,  I  concluded  there  must  be  a  considerable  dis- 


THE   THIRD   SPECIES   OF   MALFORMATION.  149 

tancc  botweoii  the  terminal  end  Cjftlie  rcfiiim  and  the  pcrhi- 
{.eiun.  1  could  not  admit  that  this  end  couimiiuicated  with 
the  bladder  or  the  urethra,  since  the  urine  passed,  contained 
no  mixture  of  fiscal  nuitter.  The  excrescence  below  the  coccyx 
made  me  suspect  that  the  rectum  might  be  above  it.  As  t'lie 
intensity  of  the  morbid  symptoms  presented  by  the  child, 
warned  me  to  empty  the  intestinal  canal  promptly,  as  a  first 
attempt  I  plunged  a  lancet  into  the  cavity  of  the  excrescence, 
and  then  cut  through  its  anterior  edge.  No  evacuation  of 
faical  matter  followed,  although  I  had  pushed  the  lancet 
nearly  an  inch  deep,  toward  the  sacrum. 

"  I  prescribed  syrup  of  saffron  with  syrup  of  poppies,  and 
cold  compresses  on  the  abdomen,  and  forewarned  the  parents 
of  the  necessity  of  recurring  to  an  operation  for  artificial 
anus.  Meanwhile  the  consent  of  the  parents  being  gained, 
the  child  had  to  be  baptized,  so  that  it  was  not  till  an  hour 
after  noon,  and  consequently  twenty  two  hours  after  birth, 
that  I  was  able  to  commence  the  operation.  The  condition  of 
the  child  was  much  worse,  and  a  distressing  hiccup  had  set 
in.  The  urine  was  evacuated  immediately  before  the  opera- 
tion. With  the  kind  assistance  of  Dr.  Wagner,  I  proceeded 
to  the  formation  of  an  artificial  anus  in  the  following  manner: 
— The  child  was  placed  with  its  back  on  a  cushion,  the  legs, 
flexed,  were  held  asunder.  I  first  enlarged  the  former  incis- 
ion towards  the  front,  so  that  it  could  be  penetrated  with  the 
little  finger.  However,  as  I  could  not  thus  reach  the  intes- 
tine, I  incised  the  integuments  of  the  perinaeum,  on  the 
median  line  from  a  point  three  lines  distant  from  the  scrotum, 
and  I  continued  the  incision  longitudinally,  and  backward 
until  I  could  easily  see  into  the  cavity  of  the  pelvis.  At  the 
depth  of  an  inch  and  a  half,  I  then  perceived  a  deep  green 
tumor,  tense  and  fluctuating,  which  extended  from  the  prom- 
ontory, towards  the  bladder.  This  tumor  descended  a  little 
when  the  abdominal  walls  were  pushed  backwards  towards 
the  cavity  of  the  pelvis.  I  no  longer  doubted  that  this  was  a 
part  of  the  rectum,  and  I  did  not  hesitate  to  seize  it  with  the 
forceps  and  bring  it  down.  It  descended  to  the  surface  of  the 
perinaeal  wound,  when  I  incised  it  from  front  to  rear.  At 
the  same  time  the  meconium  gushed  out,  with  a  great  quan- 
tity of  inodorous  gas.  The  child  then  ceased  groaning, 
breathed  deeply  and  regularly,  and  became  immediately  tran- 
quil. The  evacuation  lasted  some  time  before  it  ended; 
daring  this  time  the  edges  of  the  intestinal  wound  were  firmly 
held  by  means  of  dissecting  forceps,  quite  clear  of  the  perin- 
aeal wound,  and  afterwards  were  cleansed  by  thorough  wash- 
ing with  cold  water.     Then  by  means  of  three  points  of 


150  THE   THIRD    SPECIES    OF    MALFORMATION. 

sntnre,  I  fixed  the  edges  of  the  intestinal  wound  in  the  posi- 
tion of  the  normal  anus,  so  that  the  mucous  membrane  was 
united  to  the  skin  of  the  perinreum.  After  cutting  off  the 
excrescence  situated  below  the  coccyx,  and,  giving  an  extent 
of  three  quarters  of  an  inch  to  the  perimeal  wound,  I  united 
tlie  edges  before  and  behind  this  excrescence,  and  then  fixed 
by  points  of  suture,  the  anterior  and  posterior  angles  of  the 
intestinal  and  perinseal  wound  exactly  together.  The 
haemorrhage  during  the  operation  was  slight.  While  the 
operation  lasted  the  child  gave  no  evidence  of  pain,  but  pre- 
served the  appearance  of  one  dying,  up  to  the  moment  when 
the  contents  of  the  intestine  were  voided.  Immediately  after 
the  operation,  the  expression  of  the  countenance  was  sensibly 
ameliorated,  the  abdomen  decreased  in  volume,  and  ceased  to 
be  hot  and  painful,  and  the  extremities  grew  warm ;  all  mus- 
cular contractions  ceased.  Half  an  hour  after,  the  child  took 
the  breast  for  the  first  time  and  sucked  heartily.  It  fell 
asleep  upon  the  breast  and  did  not  wake  for  four  hours,  when 
it  uttered  loud  cries.  When  its  mother  raised  it  from  the 
bed,  she  found  it  had  evacuated  a  considerable  quantity  of 
fiscal  matter,  so  that  the  dressing  I  placed  had  been  displaced. 
The  child  passed  the  night  sleeping  and  sucking  by  turns. 
It  was  found  soiled  every  time  it  was  taken  up. 

"  The  next  morning,  I  found  the  child  in  a  satisfactory  con- 
dition, but  somewhat  weakened  ;  but  the  wound  presented 
no  sign  of  inflammation.  I  ordered  warm  chamomile,  baths, 
and  for  the  wound,  frequent  lotions  of  pure  tej^id  water.  The 
application  of  wet  compresses  could  be  of  no  avail  because 
fiecal  matter  of  a  yellowish  brown  color  was  constantly  pass- 
ing ;  the  edges  of  the  wound  seemed  perfectly  united  all 
round. 

"  The  fourth  day  after  the  operation,  the  anus  already  pre- 
sented an  oval  form,  even  when  excretion  was  not  taking 
place  ;  for  this  function  began  to  present  appreciable  inter- 
vals, lasting  nearly  half  an  hour,  as  the  mother  told  me. 
I  myself  remarked  an  interval  which  lasted  about  sixteen 
minutes.  After  taking  the  child  and  washing  the  wound 
with  injections  of  warm  water,  in  the  midst  of  slight  but 
nevertheless  appreciable  dilatations  of  the  perinsBum,  the 
wound  taking  a  circular  form,  allowed  a  small  quantity  of 
half  liquid,  yellow  fsecal  matter  to  pass  rapidly,  and  its  con- 
tact did  not  seem  to  cause  any  pain  to  the  child.  Immedi- 
ately after  new  faecal  matter  passed  from  time  to  time  with- 
out any  perceptible  motion  of  the  perinaeura,  or  the  edges  of 
the  wound.  After  which  the  edges  gathered  together  until 
the  wound  recovered  its  oval  form,  the  longitudinal  diameter 


THE   THIRD    SPECIES   OF   MALFOKMATION.  151 

corresponding;  to  tliiit  of  the  perinanira.  About  sixteen 
niinutc'S  tlieii  passed  betui-c  the  signs  above  mentioned, 
announced  a  new  evacuation.  There  appeared  no  tumet'ac- 
t'on  or  redness  of  the  edges  of  tlie  wound,  and  from  this  time, 
the  posterior  angle  only  from  which  I  iiad  cut  the  excrt'scrnce, 
secreted  a  small  quantity  of  matter  containing  a  few  puru- 
lent globules. 

"  I'he  sixth  day  after  the  operation  two  sutures  were  so 
much  loosened,  that  I  removed  them.  As  the  others  caused 
no  suppuration,  and  the  pinkings  did  not  seem  enlarged,  1  left 
them  untouched  ;  three  days  after,  I  removed  them  entirely. 
Some  of  the  pinkings  lasted  four  or  five  days,  and.  healed 
without  any  appreciable  suppuration.  At  this  moment  cica- 
trization was  complete  in  the  whole  extent  of  the  wound. 
The  form  of  the  anus  rounded  no  more,  and  the  edges 
ascended  a  little  towards  the  rectum.  The  power  of  the  child 
to  retain  its  stools  increased  to  such  a  point  that  the  evacua- 
tion of  semi-liquid  yellow  fiscal  matter  occurred  only  every 
half  hour,  and.  sometimes  only  every  hour.  Four  weeks  after 
the  operation,  the  evacuation  ceased  simultaneously  with  a 
manifest  contraction  of  the  anus  ;  and  afterwards  fiscal  matter 
of  good  consistence  passed  only  three  or  four  times  in  twenty- 
foin-  hours.  The  child  prospered  and  throve,  so  that  at  eight 
months  old  it  could  stand,  alone,  and  could  pronounce  some 
words. 

"  The  anus,  with  the  exception  of  some  slight  scars  result- 
ing from  the  sutures,  presented  no  trace  of  the  operation,  and 
seemed  altogether  like  a  normal  anus.  I  had  no  more  occa- 
sion to  visit  the  child,  and  learned  what  follows  from  the 
mother. 

"  During  the  ninth  month  two  incisor  teeth  were  cut, 
accompanied  with  violent  morbid  symptoms,  especially  a 
bronchitis  which  lasted  eight  days ;  and  enteritis.  At  the 
beginning  of  June,  1852,  the  cutting  of  an  upper  incisor  tooth 
was  accompanied  with  frequent  cough,  and  engorgement  of 
the  sub-maxillary  glands.  These  phenomena  persisted  in 
spite  of  medical  treatment,  and  with  an  astonishing  emacia- 
tion of  the  child,  until  death  occurred  on  the  twenty-fourth 
day  of  June,  1852.  Consumption  of  the  glands,  and  convul- 
sions were  stated,  to  be  the  causes  of  death.  ]N"o  autopsy  was 
made."  {ReGherohes  CUniques  et  Critiques  Siir  L'Anus 
Artificiel.  In  Archives  Generales  De  Medicine  de  Paris. 
Juillet,  1857.  p.  50.) 

Case  XLYIII. — Schultz  reports  the  case  of  a  child  that 
was  born  entirely  destitute  of  an  anus,  or  any  sign  of  one. 


152  THE   THIRD    SPECIES   OF   MALFORMATION. 

The  usual  operation  was  performed,  but  nothing  except  some 
blood   was   discharged,   and   the  child   died   on   the  follow 
ing  day. 

At  the  autopsy,  it  was  discovered  that  the  rectum,  for  the 
distance  of  nine  fincjers'  hreadth,  was  completely  obliterated, 
being  entirely  without  a  cavity,  and  that  it  was  twisted  like  a 
rope,  down  to  the  place  which  the  anus  should  have  occupied. 
{Miscellanea  curiosa  sive  ep/iem,  acad.  natur.  curiosor.  decur.  I. 
ann.  III.  observ.  9,.  p.  5.) 

Case  XLIX. — Lieutand  mentions  the  case  of  an  infant  in 
whom  the  rectum  terminated  in  a  cul-de-sac,  and  by  a  fila- 
ment at  the  upper  part  of  the  sacro-vertebral  angle.  Tliere 
was  no  trace  of  a  normal  anus.  {Bulletin  de  la  Societe  Atiat 
Paris.   Mai,   1839.   j).  86.) 

Case  L. — Yon  Ammon  observed  in  a  four  or  five  months' 
foetus  an  imperforation  of  the  anus  and  rectum.  In  this  case 
the  rectum  terminated  in  a  cul-de-sac  high  up,  and  was 
thence  continued  down  in  the  form  of  a  rudimentary  cord, 
and  attached  to  the  sacrum.     [  Vide  Plate  IV,  Figure  2.J 

This  malformation  Von  Ammon  considered  to  be  the  result 
of  an  arrest  of  development.  But  might  not  the  cord-like 
projection  have  been  an  obliteration  of  this  portion  of  the  rec- 
tum, and  the  result  of  rectitis  during  foetal  hfe  ?  {Die 
Angehorenen  Chirurgischen  KranJcheiten  des  Menschen.  S.  44. 
Berlin:   1842.) 

Case  LI. — Tlie  following  case  was  communicated  to  the 
"  Boston  Medical  and  Surgical  Journal  by  S.  Mitchell,  M.D., 
in  a  letter  dated  Cameron  Mills,  N.  Y.,  May  21st,  1851. 

'^I  was_  called  on  the  16th  instant  to  see  an  infant  son  of  J. 
L.  F.,  which  was  three  days  old.  Upon  examination,  I  dis- 
covered the  nates  to  be  perfectly  adherent ;  and,  instead  of 
the  natural  fissure  between  them,  there  appeared  to  be  only  a 
slight  ridge,  which  was  continuous  with  the  raphe  of  the  scro- 
tum. There  was  not  the  slightest  trace  of  the  anus  to  be  dis- 
covered ;  but  by  placing  the  finger  upon  its  region,  and  mak- 
ing firm  pressure  while  the  child  struggled  or  cried,  the  boM-el 
could  be  felt  to  press  upon  the  finger.  The  child  appeared 
otherwise  to  be  perfect,  and  I  learned  from  the  nurse  that  it 
had  been  lively  up  to  the  evening  before,  when  it  began  to  be 
so  drowsy  that  it  was  with  much  difiiculty  it  could  be  aroused, 
even  suflicient  to  open  its  eyes.  At  the  time  of  my  visit,  the 
stupor  was  still ^  more  profound,  with  a  purplish  and  mottled 
Btate  of  the   skin;  eyes   smiken   and   countenance  pinched; 


THE   THIRD   SPECIES   OF   MAUOUMATION,  153 

denotiiif^  tliat  tlic  vital  powers  of  the  RyKtein  were  f?Iving 
way,  probaljly  from  tJie  irritation  ariaiii^  from  the  retained 
secretions  in  the  bowels.  I  gave  it  as  my  opinion  to  the 
parents,  that,  on  account  of  its  weakness,  it  was  quite  proba- 
ble that  an  operation  would  not  ])revent  a  fsxtal  termination  ; 
but,  of  course,  its  only  chance  for  life  was  in  o])erating.  They 
decided  for  me  to  operate.  Accordingly,  with  the  assistance 
of  my  brother.  Dr.  John  Mitchell,  1  proceeded  as  follows. 
The  child  was  placed  upon  the  knees  of  an  assistant,  with  its 
face  downward,  and  the  nates  exposed.  I  then  made  an 
incision,  Avith  a  small  scalpel,  seven  or  eight  lines  in  length, 
commencing  a  little  anterior  to  the  os  coccyx,  cutting  througli 
the  skin  and  a  firm  ligamentous  growth  immediately  beneath. 
I  now  used  a  long  narrow  straight  bistoury,  which  I  carried 
up  in  the  direction  of  the  curve  of  the  sacrum  about  one  and 
a  half  inch,  when  it  entered  the  bowel,  which  was  followed 
by  a  copious  discharge  of  gas  and  meconium.  There  was  not 
more  than  one  •  or  two  teaspoonfuls  of  blood  lost  during  the 
operation,  and  yet,  at  its  termination,  I  found  my  little  patient 
was  sinking  rapidl}^  from  the  shock  upon  the  nervous  system. 
Various  remedies  and  expedients  were  resorted  to,  to  arouse 
him,  but  without  success.  His  gasps  for  breath  continued  to 
grow  less  and  less  frequent,  until  he  ceased  to  breathe  ;  but, 
as  his  heart  continued  to  beat  freely,  my  brother  commenced 
tlie  use  of  artificial  respiration.  I  could  feel  his  heart  beat 
stronger  and  faster  every  time  his  lungs  were  inflated ;  and, 
after  using  it  for  five  or  ten  minutes,  we  had  the  satisfaction  of 
again  seeing  the  little  fellow  catch  for  breath,  which  he  con- 
tinued to  do  more  and  more  frequently  until  natural  respira- 
tion was  established.  I  mention  this  as  an  example  of  the 
efficacy  of  artificial  respiration,  when  properly  applied.  The 
child,  undoubtedly,  was  in  a  state  of  syncope,  so  profound 
that  all  the  usual  remedies  had  failed  to  arouse  him.  A  mod- 
erate dose  of  castor  oil  was  now  ordered  to  be  given,  to  sweej) 
out  the  bowels,  and  a  few  drops  of  brandy  to  be  taken  at 
short  intervals  in  a  little  sweetened  milk  and  water,  until  he 
should  rally ;  and  a  tent,  smeared  with  simple  cerate,  to  be 
constantly  kept  in  the  artificial  orifice  to  prevent  its  union. 

"  Saturday,  ITtli. — Less  stupor.  Bowels  have  moved  seve- 
ral times  since  last  evening,  but  he  still  remains  quite  feeble. 

"  Sunday,  18th. — Sank  and  died  from  inanition. 

"  I  have  every  reason  to  believe  that  had  the  operation  been 
performed  earlier,  before  the  vital  powers  began  to  give  way, 
it  would  have  been  successful."  {Boston  Medical  and  Surgi- 
cal Journal.    Vol.  XLIY.  xj.  376.    Boston :  1851.) 


154  THE   THIRD   SPECIES    OF   MALFORMATION. 

Case  LII. — Mr.  Eedfern  Dnvies,  of  Birmingham,  England, 
reports  the  following  case  of  imjoerforate  anns  and  rectum : 

"  The  mother  of  the  child,  a  healthy  primipara  of  twenty- 
eight  years  of  age,  was  delivered  of  it  at  full  time,  on  Decem- 
ber 19th,  1857.  The  child  seemed  to  all  appearance  at  birth 
well  and  flourishing ;  but  on  the  third  day,  no  meconium  hav- 
ing come  away,  the  medical  attendant  elicited,  in  answer  to 
his  inquiries,  that  there  existed  some  malformation  about  the 
child's  hottom^  which  the  nurse  explained  not  having  seen  be- 
fore, owing  to  her  bad  sight.  An  imperforate  anus  was  at 
once  found  to  exist. 

"  On  being  summoned,  December  22d,  by  my  friend.  Dr. 
Cornelius  Suckling,  under  whose  care  the  child  was,  the  fol- 
lowing appearances  presented  : — a  well  formed  male  child ; 
seems  weakly,  but  is  tranquil.  Urine  quite  clear,  and  made 
freely.  On  examining  the  perinseum  no  anal  aperture  is 
seen  ;  the  skin  passes  continuously  from  side  to  side  ;  median 
raph^  very  marked  and  distinct.  In  the  site  of  the  anus  the 
integument  puts  on  a  different  color  to  adjacent  parts;  it  is 
darker  and  has  a  peculiar  appearance,  simulating  the  usual 
anal  wrinkles.  On  examining  with  the  finger,  and  at  the 
same  time  pressing  upon  the  abdomen,  or  when  the  child 
cries,  it  is  thought  that  in  the  direction  of  the  rectum  a  fluc- 
tuation can  be  made  out ;  the  sensation  is,  however,  by  no 
means  defined  or  certain.  In  all  other  directions  an  elastic, 
firm  and  resisting  structure  is  evident.  The  bony  outlines  of 
the  pelvis  natural.  The  abdomen  is  bulging,  hard  and  tym- 
panitic on  percussion. 

"  Diagnosis.  Absence  of  anus  and  of  a  portion  of  the  rec- 
tum, probably  from  one  to  two  inches.  Rectum  does  not 
open  into  viscera. 

"An  incision  which  upon  measurement,  was  found  to  be 
five-eighths  of  an  inch,  was  commenced  in  the  central  line  of 
the  perinseum,  down  to  the  coccyx,  in  the  part  alluded  to  as 
marking  the  sight  of  the  anus.  Introducing  the  little  finger, 
the  sensation  of  the  end  of  the  rectum,  though  very  distant,  is 
now  certain.  Guided  by  that  sensation,  by  the  curve  of  the 
sacrum,  and  by  the  tuberosities  of  the  ischium,  the  incision 
was  carried  by  very  gentle  progression,  cutting  fibre  by  fibre, 
to  a  distance  of  two  inches  and  a  quarter,  as  was  ascertained 
by  actiial  measurement  both  at  the  time  and  afterwards.  Tlie 
extremity  of  the  gut  being  satisfactorily  recognised,  an  inci- 
Bion  was  made  into  it,  and  a  gi-ooved  director  pushed  into 
the  gut.  An  immediate  escape  of  gas,  wliich  was  very  per- 
ceptible both  to  the  ears  and  noses  of  the  bystanders,  as  also 
by  the  welling  out  by  the  side  of  the  director  of  meconium. 


THE    TllUtD    SPECIES    OE    MALEUKMATKJN.  155 

announced  that  tlic  rectum  was  opened.  There  was  hut  very 
little  loss  of  hlood,  estimated  hy  the  nurse  as  under  a  teaspoon- 
ful.  A  dose  of  castor  oil  administered  directly  ;  a  small  oiled 
tent  introduced  into  the  wound ;  the  child  was  put  to  hed. 

"  Vesj)ere,  10  P.  M. — No  more  meconium  luis  passed. 
Child  seems  easy. 

"  Deceviher  23cl.  10  A.  M. — No  meconium  passed  ;  child 
refuses  the  hreast,  seems  fretful  and  ailing.  On  withdrawing 
the  tent  and  introducing  the  finger  into  the  wound,  a  few  co- 
agula  are  found  at  the  top,  closing  the  opening  into  the  gut ; 
on  their  being  removed,  a  fresh  escape  of  flatus  and  meconium, 
which  now  passes  easily  through  the  wound.  He  was  ordered 
a  j)urge  of  jalap. 

"  Vesj)ere,  same  day. — Child  seems  easy,  but  refuses  nour- 
ishment ;  meconium  comes  away  ;  urine  clear. 

"  December  ^Uh. — Meconium  and  faeces  come  away  easily. 
Child  refuses  nourishment. 

"  Vesj>ere. — About  the  same, 

"  December  2bth. — Died  about  noon. 

"  Post  Mortem. — Body  of  a  dwindled  appearance.  Upon 
opening  the  cavity  of  the  abdomen,  no  signs  of  peritonaeal  or 
inflammatory  miscJiief  could  be  any  where  traced ;  the  con- 
tents appeared  quite  healthy,  and  the  anatomical  relations  of 
the  viscera  as  usual,  save  that  there  is  a  deficiency  in  the  rec- 
tum, which  is  found  to  terminate  in  an  infundibuliform  cul-de- 
sac,  about  the  middle  of  the  sacrum.  Upon  oj)ening  it,  it 
is  found  to  contain  healthy  fjBces ;  and  presents  about  one 
fourth  of  an  inch  posterior  to  the  cid-de-sac,  on  its  lower  sur- 
face, an  aperture  three  eighths  of  an  inch  in  diamater,  through 
which  a  jjrobe  being  introduced,  passes  out  through  the  arti- 
ficial anus  in  the  perinseum.  The  bladder  is  found  quite  nat- 
ural. Tlie  rectum,  as  before  said,  terminated  in  a  cid-de-sac 
of  an  infundibuliform  shape,  from  which  is  prolonged,  for 
about  three  fourths  of  an  inch,  a  fibrous  cord.  No  muscular 
fibres  could  be  found  corresponding  to  the  anus,  though  looked 
for,  even  by  the  microscope." — {Edinhurgh  Medical  Journal. 
m.  XXXIIl.  March,  1858.  p.  808.) 

Case  LIU. — Petit  gives  the  case  of  a  child  in  which  both 
the  anus  and  the  rectum  were  imperforate.  A  deep  incision 
was  made  with  the  lancet  into  the  integument  of  the  ])art 
where  the  anus  ought  to  be,  and  the  wound  thus  made  was 
dilated  with  the  finger,  yet  no  rectum  could  be  discovered. 
Three  hours  afterwards,  a  soft  and  dark  tumor,  the  size  of  a  plum, 
presented  itself  at  the  opening  and  completely  concealed  it. 
This  tumor  was  punctured,  the  meconium  discharged,  and  the 


156  THE   THIRD    SPECIES    OF   MALFOEMATIOX. 

child  much  relieved ;  yet  it  did  not  entirely  rally,  but  contin- 
ued to  linger  on,  suffering  more  or  less,  until  the  eighth  day, 
when  it  expired. 

At  the  autopsy  Petit  discovered  that  the  tumor  was  the 
posterior  jDart  of  the  superior  portion  of  the  rectum,  which  had 
been  forced  down  into  the  incision,  by  the  straining  efforts  of 
the  child  to  evacuate  its  bowels,  and  that  it  formed  a  kind  of 
hernia.  The  inferior  portion,  or  lower  third  of  the  rectum 
was  found  obliterated,  without  the  sign  of  a  cavity  and  like  a 
hard  cord,  and  into  which  a  very  fine  pointed  probe  was  with 
much  force  and  difficulty  introduced. — {Memoire  de  VAcad- 
emie  Royal  de  Chirurgie.     tome  II.  p.  237.   Paris  :  1781.) 

Case  LIY. — Saviard  reports  the  case  of  a  new-born  child, 
which  presented  an  imperforation  of  both  the  anus  and  the 
rectum.  Tliere  was  no  sim  whatever  of  an  anus,  and  the 
rectum  terminated  in  a  cul-de-sac.  He  plunged  a  lancet  into 
the  place  which  the  anus  should  have  occupied,  in  the  direc- 
tion of  the  rectum,  and  after  penetrating  to  the  depth  of  two 
finger'' s  Jjreadth  it  entered  the  blind  sac,  and  simultaneously 
Avith  the  withdrawal  of  the  instrument,  the  meconium  flowed 
out  abundantly,  and  the  child  was  saved.    {Oj?.  clt.) 

Cases  LV — LYI. — Heister  observes  that  he  saw  two  chil- 
dren, in  both  of  whom  the  anus  was  imperforate,  and  the 
rectum  completely  closed  and  terminating  as  high  up  as  the 
superior  part  of  the  sacrum.  The  operation  in  each  case  was 
performed  with  a  trocar ;  but  the  result  in  both  cases  was 
death.  {Institutiones  CJdrurgiccB,  P.  11,  Sec.  Fi,  Chajy. 
CLXIIl.  Amstelcedami,  1739.) 

Cases  LYII — LYIII. — Adrian!  reports  having  seen  two 
infants,  in  both  of  which  there  was  imperforation  of  the  anus, 
the  rectum  terminating  in  a  blind  sac.  In  one  of  the  children 
a  trocar  was  plunged  in  the  direction  of  the  rectum  to  the 
depth  of  the  little  finger,  the  cul-de-sac  was  reached  and 
meconium  flowed,  l3ut  the  child  died.  Tlie  other  one  died 
without  operation.  {Puysch,  Adve?'sarla  Anaiomicd  Decad. 
II.  c.  10.  p.  43.) 

Case  LIX. — ^Tlie  following  case  of  imperforation  of  the  anus 
and  rectum  is  recorded  by  Wolf,  who  after  having  thrust  a 
large  lancet  into  the  perineum  a  few  lines  in  front  of  the  os 
coccygis,  to  the  depth  of  two  inches,  failed  to  reach  the 
meconium.  lie  afterwards,  however,  with  a  pharyngotomus 
succeeded  in  piercing  the  end  of  the  rectum,  and  letting  out 


Tin:   TIIIUD    Sl'ECIKS    OF   MALl'OKMATION.  157 

its  contents.  What  was  very  rcmarlvublo  in  this  case,  the 
maltVtniKition  was  not  discovered  till  the  eveiiiiio-  of  tlie 
twelfth  day  after  the  birth  of  the  child,  it  having  liad  no  evac- 
uation from  its  bowels  during  all  this  time  ;  when  it  was 
attacked  with  vomiting,  hiccuj)  and  convulsions,  the  abdomen 
was  distended,  hard  and  painful  upon  pressure,  and  there  was 
great  prostration  of  strength.  The  operation  uuder  these 
unfavorable  circumstances  was  performed  on  the  thirteenth 
day,  and  subsequently  by  the  use  of  enemata  and  tents,  the 
child  ultimately  recovered.  {Langenheck,  Neue  Bihliothek 
far  die  Chiriwgie  %uid  Oj>hthalmologle.  Band  III.  S.  231. 
Hanover,  1813—22.) 

Cases  LX — LXI. — ^Professor  James  Jones,  of  New  Orleans, 
previously  alluded  to,  reports  the  two  following  unfortunate 
cases  of  imperforation  of  the  anus  and  rectum. 

I'ii'si  Case. — "  My  next  case,"  says  Dr.  Jones,  "  was  in 
consultation  with  my  friend  Dr.  Richard  Bein,  on  the  lltli 
of  August,  1856,  The  little  boy  was  born  on  the  ninth,  pre- 
sented the  usual  symptoms,  and  Dr.  B.  made  an  attempt,  in 
company  wath  Dr.  Hunt,  to  cross  the  river  during  the  gale  of 
August  the  10th,  to  relieve  him  by  an  operation  ;  but  after 
several  hours  drifting  about  they  returned  home  without  being 
able  to  get  across.  Dr.  H.  being  unwell,  I  went  over  next 
day,  with  Dr.  Bein,  We  found  the  child  in  great  distress, 
the  abdomen  very  tumid  and  renitent,  with  constant  vomiting 
of  a  yellowish  thin  lluid.  On  examination,  the  anus  being 
imperforate,  we  proceeded  at  once  to  open  it  with  a  bistoury, 
which,  after  being  carefully  introduced  to  the  depth  of  an 
inch  and  a  quarter,  gave  issue  to  a  large  quantity  of  meco- 
nium. The  accumulated  cathartics  produced  so  much  purga- 
tion that  Dr.  B.  was  compelled,  during  the  evening,  to 
administer  an  anodyne  mixture  to  check  their  debilitating 
operation. 

"  On  the  twelfth  we  introduced  a  caoutchouc  tube  to  keep 
the  passage  open.  The  abdomen  was  greatly  reduced,  the 
child  sucked  and  swallowed,  and  we  hoped  that  it  would  con- 
tinue to  improve. 

"  On  the  19th  I  saw  it  again.  The  operations  had  ceased  ; 
the  abdomen  was  again  hard,  although  not  so  much  inflated. 
Tlie  opening  having  contracted,  we  dilated  it  by  introducing 
the  dressing  forceps  and  gently  spreading  the  blades  ;  the 
orifice  was  again  kept  dilated  with  a  gum  catheter.  The 
general  appearance  of  the  child  was  wretched ;  it  moaned 


158  THE   THIRD    SPECIES   OF   MALFORMATION. 

and  whined  continually,  never  slept,  rejected  everything,  and 
exhibited  signs  of  peritoneal  inflammation  of  a  fatal  tendency. 
By  the  use  of  camphorated  mercurial  ointment  to  the  abdo- 
men, emollient  enemata,  and  two  or  three  minute  doses  of 
calomel,  it  revived  slightly  and  had  a  few  oj)erations,  urinat- 
ing as  usual." 

"  On  the  23rd  I  saw  it  again  by  the  request  of  Dr.  B.  and 
although  evidently  sinking,  it  lingered  until  the  25th. 

"  On  the  26th  the  body  was  opened  by  Dr.  Bein,  myself, 
and  Dr.  F.  Poland,  at  that  time  a  student  of  medicine.  The 
intestines  were  somewhat  distended,  and  were  also  generally 
adherent  by  organized  bands  of  lymph.  Internally  there  was 
much  disseminated  inflammation.  The  rectum  terminated  in 
a  pouch,  which  being  doubtlessly  softened  in  its  attachments 
by  inflammation,  pealed  off  entire  from  the  pelvic  surface  of 
the  perinseum.  I  have  it  now  in  alcohol.  Tlie  friends  were 
waiting  to  bury  the  infant,  and  we  did  not  examine  into  the 
state  of  the  sphincter  or  of  the  other  muscles." 

"  It  was  very  evident  that  in  this  case  enteritis  and  perit- 
onitis were  the  causes  of  death.  The  only  question  being 
how  they  should  have  occurred,  when  the  operation  had 
been  so  successfully  performed  at  so  early  a  period. 

Second  Case. — "On  the  morning  of  the  17th  of  ISToveraber, 
1857,"  says  Professor  Jones,  ''  I  was  called,  before  day,  to 
see  Mrs.  R,  Franklin  Street,  in  labor.  I  found,  on  my 
arrival,  that  she  had  been  delivered  several  hours  previously 
of  one  child  and  that  she  was  much  exhausted  by  her  efforts 
to  expel  another.  I  found  the  membranes  of  the  second 
ovum  unruptured,  and  felt  the  hand  and  arm  presenting 
through  them.  I  immediately  ruptured  the  bag,  pushed  up 
the  right  hand  and  arm,  brought  down  the  head,  and  in  three 
pains  it  was  delivered.  I  felt  the  chord  prolapsed  and  pulse- 
less as  I  pushed  up  the  hand.  The  child  was  born  in  five  or 
six  minutes  after  I  commenced  to  interfere,  but  it  was 
asphyxiated,  without  the  slightest  pulsation  about  the  heart, 
and  nothing  could  revive  it. 

"  On  the  18th,  in  the  morning,  the  surviving  child  had 
passed  nothing  from  its  bowels,  although  unfortunately,  it 
had  taken  considerable  quantities  of  castor  oil,  olive  oil,  and 
all  of  the  usual  teas  children  are  compelled  to  swallow.  Its 
belly  was  already  tumid  and  tense  the  enlarged  veins 
showing  the  intestinal  obstruction.  On  returning,  several 
hours  afterwards,  with  the  proper  instruments,  I  found  the 
child  worse  ;  it  was  very  restless,  evidently  in  pain,  and  had 


THE   THIRD   SPECIES    OF   MALFORMATION.  159 

rejected  latterly,  every  tliirifij  put  into  the  stomach.  It  had 
never  attcin])ted  to  suck.  Dr.  Stone  beinir  in  the  vicinity, 
we  examined  the  case  together,  and  found  tlje  anus  completely 
imperforate.  A  small  incision  made  unsuccessfully  with  the 
bistoury,  was  repeated  afterwards  with  the  lancet,  which 
beino;  driven  to  the  depth  of  more  than  an  inch,  was 
followed  by  a  copious  evacuation  of  meconium  and  flatus  ; 
the  belly  subsided  immediately  ;  the  vomiting  ceased,  and 
the  child  did  not  give  much  indication  of  pain  ;  but  refused 
to  suck ;  swallowed  with  difficulty,  and  continued  to  decline. 

"On  the  20th,  a  gum  catheter  was  introduced,  after 
extending  the  puncture,  more  meconium  followed.  In  the 
evening  of  the  same  day,  the  child  died. 

"  On  the  morning  of  the  22nd,  M.  Capdevielle  and  my  son 
made  a  post  mortem  examination,  and  brought  me  the 
intestines.  The  peritongeum  was  inflamed  ;  the  intestines 
somewhat  distended,  and  the  colon  very  much  inflamed,  and 
tilled  with  a  mixture  of  meconium  and  of  blood,  which 
probably  came  from  the  incision  I  made  last,  in  enlarging 
the  opening.  The  rectum  terminated,  as  in  the  case  with  Dr. 
Bein,  in  a  pouch,  on  the  pelvic  side  of  the  perinieum.  The 
incision  Avas  through  cellular  membrane,  and  there  was  no 
appearance  of  a  sphincter."  {New  Orleans  Medical  and 
Surgical  Journal.      Vol.  XV.     Pp.  99,  101.     1858.) 

Case  LXII. — Tlie  following  interesting  case  was  communi- 
cated to  the  ^^  Boston  Medical  and  SurgicalJournal^^  by  Dr. 
Thomas  P.  Hill,  of  Sanbornton,  IST.  H.,  in  a  letter  dated 
December  4th,  1839. 

"  Some  time  in  August  last  I  w\as  called,  in  the  niglit,  to 
visit  Dr.  Webster's  family,  of  Hill.  Mrs.  W.  had  been  con- 
fined, the  previous  afternoon,  of  a  male  child,  and  M'as  then 
comfortable.  JSTothing  unusual  appeared  in  the  child  at 
birth  ;  its  exterior  was  perfect,  so  far  as  had  been  discovered, 
and  its  features  were  uncommonly  beautiful.  Very  soon, 
however,  it  was  seized  wath  spasms,  attended  with  a  livid 
appearance  over  the  face  and  neck,  and  in  some  degree  over 
the  whole  body,  more  especially  when  anything  was  put  into 
its  mouth.  The  nurse  told  me,  on  my  arrival,  that  she 
believed  the  child  could  not  swallow.  Finding  nothing  in 
the  mouth  to  obstruct  the  passage  to  the  throat,  and  in  order 
to  satisfy  myself  as  to  wdiat  the  nurse  had  stated,  I  directed 
her  to  give  a  teaspoonful  of  warm  drink.  The  child  made  no 
effort  to  swallow,  but  was  immediately  convulsed,  accompa- 
nied with  the  lividity  above  mentioned,  and  the  drink  which 


160  THE   THIRD    SPECIES    OF   MALFORMATIOX. 

had  been  given  was  returned  by  tlie  mouth  and  nose,  mixed 
with  bloody  mucus.  Supposing-  there  might  possil.)ly  be  some 
spasmodic  stricture  of  the  oesophagus,  and  that  gently  stinni- 
lating  the  rectum  would  remove  the  difficulty,  I  advised  an 
injection  of  warm  water  per  anum.  But  in  attemjjting  to 
comply  with  the  direction,  no  outward  passage  could  be 
found  ;  not  even  the  vestige  of  an  anus  was  seen ;  all  was  as 
smooth  as  the  hand,  except  the  raphe,  which  extended  from 
the  scrotum  to  near  the  point  of  the  coccygis.  All  the  cir- 
cumstances of  the  case  considered,  it  was  not  thought  advisa- 
ble to  attempt  any  operation,  and  I  took  my  leave,  expecting 
soon  to  hear  that  the  child  was  dead.  It  remained,  however, 
much  the  same  till  the  next  day ;  it  would  sometimes  lay 
quiet,  as  though  nothing  ailed  it ;  and  the  anxious  j)arents, 
desiring  that  something  might  be  done,  if  possible,  to  relieve 
the  little  sufferer  from  its  imj)ending  fate,  sent  for  me  again, 
and  two  others  of  the  faculty.  The  result  of  this  consultation 
was,  that  an  attempt  be  made  to  open  a  passage  into  the  rec- 
tum. An  incision  was  made  in  the  integuments,  about  an 
inch  long,  half  way  between  the  scrotum  and  coccygis,  and 
an  abscess  lancet  introduced  about  an  inch  and  a  half  in  the 
direction  to  pierce  the  lower  portion  of  the  gut,  if  it  were  in 
its  natural  situation.  No  portion  of  the  intestine  was  reached, 
and,  of  course,  the  operation  failed — and  the  poor  little  thing 
was  again  left  to  its  fate.  It  lingered  a  day  or  two,  without 
any  change  of  symptoms,  and  expired. 

"  Postmortem  Examination.  The  abdomen  was  consider- 
ably swollen,  from  gaseous  distention  of  the  intestines.  No 
other  abnormal  appearance  was  noticed  in  the  alimentary 
canal,  except  at  its  extremities.  On  dissecting  out  the  lower 
portion  of  the  track  it  was  found  that  \X\q  rectum,  instead  of 
pursuing  its  natural  course  down  the  concave  surface  of  the 
OS  sacrum  and  coccygis,  took  an  anterior  direction  towards  the 
bladder,  and  terminated  in  a  cul-de-sac  upon  the  posterior 
portion  of  the  neck  of  that  viscus.  The  bladder  could  be 
inflated  from  the  rectum  by  means  of  a  blow-pipe,  though 
the  communication  could  not  be  traced  by  a  common  probe. 
[  VhU  Plate   IV,  Figure  3.] 

"  The  condition  of  the  upper  end  of  the  tube  was  still  more 
remarkable.  The  pharjmx  terminated  in  another  cnl-de-sac 
about  two  inches  below  the  fauces.  The  oesophagus,  tracing 
it  upward  from  the  cardiac  orifice  of  the  stomach,  diminished 
in  size  as  it  ascended,  till  it  finally  ended  in  a  few  scattered 
fibres,  jjassing  through  an  opening  in  the  posterior  -\)SA't  of  the 
trachea,  to  be  inserted  upon  its  inner  surface."    {Boston  Med- 


TIIK    THIUD    6PECIK8    OF   MALFORMATION.  161 

ical   and    Surgical   Journal.      Vol.    XXL    r>.    320.      Bo!<- 
ton:  1839.) 

The  following  cases  all  belong  to  this  the  third  species,  und 
should  be  thus  classed.  Their  history  and  descri2)tion,  for 
obvious  reasons,  will  be  given  in  the  chapter  on  Abdominal 
Artificial  Anus.     [  Vide  Chapter  XI.'] 

Cases— CCLY—  CCLVI—  CCLYIII-CCLXI— CCLXIV 
CCLXV—  CCLXYI  —  CCLXIX  —  CCLXX  —  CCLXXI  — 
CCLXXm  —  CCLXXIV  —  CCLXXYI  —  CCLXXVIII  — 
CCLXXX— CCLXXXI— CCLXXXII— CCLXXXVI. 


11 


THE    FOUETH    SPECIES   OF  MALFOEMATION. 

SECTION      I. 

DESCRIPTION. 

This  species  of  malformation  is  characterized  by  the  anus 
being  usually  quite  normal,  whilst  the  rectum  at  a  variable 
distance  above  it,  is  either  obliterated,  partially  or  wholly 
absent,  or  occluded  by  a  thin  or  thick  annular  membranous 
septum,  like  a  diaphragm — presenting,  as  it  were,  a  double, 
or  an  external  and  internal  cul-de-sac.  [  Vide  Plate  VI, 
Figure  1.] 

Sometimes  the  rectum  is  intercejDted  at  several  points  by 
transverse  membranous  septa ;  its  diameter,  however,  at  these 
points  remains  undiminished,  and  the  canal,  with  the  excep- 
tion of  these  partitions,  being  perfectly  normal. 

Dr.  Friedberg,  of  Berlin,  mentions  a  case  in  which  the  walls 
of  the  rectum  some  distance  above  a  well-formed  anus,  were 
adherent  at  two  points,  and  the  canal  at  these  places  obliter- 
ated.   [  Tide  Case  LXXXIV.^ 

Professor  James  Jones,  of  New  Orleans,  saw  a  case  in 
which  the  anus  was  normal,  but  the  rectum  a  short  distance 
above  it,  was  entirely  wanting.     [  Vide  Case  LXXX  VII.] 

Schenck  relates  a  case  in  which  the  parietes  of  the  rectum 

above  a  natural  anus,  were  closely  united  at  two  places,  as  if 

glued  together ;  and  at  two  other  points  the  rectum  was  occlu. 

ded  by  two  annular  membranous  septa.    [  Vide  Case  ZXIIL] 

M.  Yoillemier  reports  a  case  in  which  the  rectum,  above  a 
(102) 


THE   FOUIITII  SPECIES    OF   MALFORMATION.  163 

natural  amis,  was  divided  by  four   membranous  partitions. 
[  Vide  Case  ZXXXIIL] 

The  late  and  lamented  Dr.  Buslie,  of  New  York,  mentions 
a  case  in  Avhicli  the  rectum,  above  a  normal  anus,  was 
obstructed  by  two  membranous  partitions.  [  Vide  Case 
ZXXXII.] 

Goeschler,  of  Prague,  reports  a  similar  case  to  that  of  Dr. 
Bushe.     [  Vide  Case  XCII.] 

The  situation  of  the  obstruction  or  membranous  partition 
will  be  found  to  vary  from  one  half  to  two  and  a  half  inches 
from  the  margin  of  the  anus.  It  is  sometimes  quite  delicate, 
thin  and  semi-transparent,  and  easily  perforated  or  ruptured, 
by  the  probe  or  the  finger ;  at  other  times  it  is  thick  and 
hard.  Trioen  relates  a  case  in  which  the  ano-rectal  septum 
was  one  inch  thick,  and  of  the  consistence  of  horn.  [  Vide 
Case  ZXVII.] 

Engerran  witnessed  a  case  in  which  the  rectum,  above  a 
well-formed  anus,  was  indurated,  puckered  and  drawn  into  a 
knot.     [  Vide  Case  LXVI.] 

In  some  instances,  at  the  normal  situation  of  the  anus,  a 
wrinkled  depression  like  the  umbilical  pit  is  observed,  but 
when  you  come  to  examine  carefully  and  separate  the  wrin- 
kles you  will  find  no  anus  there,  but  merely  a  slight  depres- 
sion. Such  cases  must  not  be  confounded  with  those  under 
consideration.    [  Vide  Cases  XXXVIII — XXXIX?\ 

From  the  preceding  observations  it  will  clearly  appear  tliat 
a  well-formed  anus  does  not  by  any  means  prove  that  the  rec- 
tum is  normal,  that  it  is  not  obstructed,  or  that  it  is  not  par- 
tially or  wholly  wanting.  This  species  of  malformation  pre- 
sents a  form,  therefore,  which  is  at  once  well  calculated  to 
deceive  the  most  experienced,  unless  an  exploration  is  made. 
The  circumstance  of  tlie  normal  state  of  the  anus  in  these 
instances  is  the  more  serious,  because  it  never  leads  to  the 
suspicion  that  an  obstruction  of  the  rectum  exists,  but  quite 
to  the  contrary — thus  leaving  the  nurse  or  the  accoucheur,  or 


164  THE   FOUKTH    SPECIES    OF    MALFOEMATIOX. 

both,  in  a  fatal  securitj',  till  aroused  sooner  or  later  by  grave 
symptoms  presenting  themselves. 

Every  nurse  and  accoucheur  should  be  impressed  with  the 
importance  of  making  a  visual  and  tactile  examination  of  the 
anal  region  of  every  child  which  fails  to  pass  meconium  or 
fsecal  matter  within  the  first  twelve  hours  after  birth,  and  not 
to  wait  for  urgent  symptoms  to  present  themselves  before  this 
exploration  is  made.  The  examination  may  be  made  by 
either  introducing  the  extremity  of  the  little  finger  well  oiled, 
an  elastic  bougie,  or  a  probe,  into  the  anal  orifice ;  or  by  an 
injection  of  a  little  warm  water,  which  if  it  meets  with  an  ob- 
struction will  be  immediately  returned.  An  ignorant  nurse, 
however,  may  here  be  deceived  herself,  and  deceive  others. 
She  will  declare  that  the  child's  fundament  is  natural,  and 
that  she  has  given  the  child  several  injections  into  its  bowel, 
when  perhaps  not  a  drop  of  the  fluid  has  passed  from  the 
syringe,  the  end  of  the  pipe  having  been  pressed  against  the 
obstruction  in  the  bowel  which  closed  it,  the  fluid  passed  by 
the  piston  as  it  was  slowly  pressed  down,  and  accumulated  at 
the  head  of  the  cylinder,  without  a  drop  passing  out.  This 
can  be  verified  at  any  time  by  filling  the  cylinder  with  a  fluid, 
and  placing  the  finger  firmly  against  the  end  of  the  pipe,  and 
then  slowly  forcing  down  the  piston. 

The  exploration  in  these  cases  should  be  conducted  in  the 
same  manner  as  recommended  in  the  preceding  chapter.  The 
finger  inserted  into  the  anus  can  generally  at  once  detect  the 
membranous  variety  of  this  species,  by  the  fluctuation,  pro- 
vided sufficient  meconium  and  gas  have  accumulated,  especi- 
ally during  the  straining  efforts  of  the  child  to  deficate ; 
sometimes  by  these  eff"orts  the  distended  membrane  is  forced 
down  so  low  as  almost  to  be  visible,  and  by  dilating  the  anus 
a  little  may  be  brought  to  view.  When  seen,  the  protrusion 
is  of  a  dusky  color.  The  small  speculum  ani  can  here  be  used 
with  advantage  to  dilate  the  anus  and  canal,  and  enable  the 


THE   FOUUTir    SPKCIES    OF    MALFORMATION.  105 

snri^eon  to  ceo  tlie  obstruction,  lie  can  also  in  tliese  cases 
<i])erate  through  tliis  instrument. 

From  tlie  number  of  recorded  cases  of  this  species  of  con- 
genital malformation,  I  am  naturally  led  to  the  conclusion 
that  it  is  by  no  means  uncommon. 

Prognosis.  Should  the  obstruction  of  the  rectum  consist  of 
a  mere  superficial  membranous  septum,  the  treatment  would 
be  simple  and  easy,  and  the  success  highly  probable ;  on  the 
contrary,  however,  should  it  consist  of  a  dense  and  thick  mem- 
brane, a  partial  or  total  absence  of  the  rectum,  or  a  puckered 
and  indurated  condition  of  its  parietes,  the  case  would  be  in- 
finitely more  serious,  and  the  success  of  the  treatment  much 
less  certain. 


SECTION    II. 
THE  TREATMENT. 

1.  If  the  obstructing  membrane  is  thin  and  friable  it  may 
be  broken  down  wath  a  probe  or  -with  the  little  finger.  Should 
it,  on  the  contrary,  be  firm  and  unyielding,  it  should  be  punc- 
tured w^ith  the  sharp-pointed  bistoury,  wrapped  with  thread 
or  a  narrow  strip  of  linen,  to  within  a  few  lines  of  its  extrem- 
ity, and  cautiously  carried  into  the  passage  on  a  grooved 
director,  or  glided  along  the  finger.  This  puncture  should 
then  be  freely  enlarged  crucially  with  the  probe-pointed  bis- 
toury. The  opening  thus  made  should  be  kept  free  by  the 
frequent  introduction  of  the  little  finger  well  oiled,  or  by 
tents  of  lint  besmeared  with  cerate,  and  afterwards  dilated  by 
elastic  bougies ;  or  the  silver  or  elastic  tubes  should  be  used, 
as  already  recommended. 

2.  When  the  ano-rectal  partition  is  very  thick  and  hard,  the 
method  of  M.  Amussat  is  the  best — that  is,  after  having  dila- 
ted the  anus,  or  slit  it  at  its  posterior  part,  and  on  its  side,  to 


166  THE   FOURTH    SPECIES   OF   MALFORMATION. 

detach  the  mucous  membrane,  draw  down  the  rectum  from 
the  pelvic  cavity,  cut  olf  its  inferior  extremity  above  the  sep- 
tum, and  then  suture  it  either  to  the  sphincter  or  to  the  skin. 
Tliis  method  should  always  be  adopted  if  it  possibly  can  be 
done,  as  the  tendency  to  contraction  at  the  situation  of  the 
occlusion  is  always  very  great  in  these  cases.  If  this  is  im- 
possible, the  end  of  the  rectum  should  then  be  opened  as  by 
tlie  ordinary  method  and  treated  accordingly. 

3.  In  an  interesting  case  of  imperforate  rectum  accompa- 
nied with  a  normal  anus,  M.  Amussat  operated,  as  if  no  anus 
whatever  existed,  and  as  if  the  rectum  was  completely  defi- 
cient throughout  the  entire  extent  of  its  anal  extremity,  by 
cutting  backward  and  drawing  the  rectum  not  downwards  to 
the  anus,  as  he  at  first  advised,  but  directly  backwards.  This 
case  I  have  translated  entire,  together  with  bis  reflections 
upon  it.     [  Vide  Case  LXXX  F.] 

4.  M.  Amussat  is  of  opinion  that  in  these  cases  the  mere 
destruction  of  the  septum,  however  thin  and  delicate  it  may 
be,  is  entirely  insufiicient,  and  always  fails  in  consequence  of 
the  difficulty  of  keeping  an  opening  above  the  anus  patulous 
— and  "  that  no  case  can  he  cited  in  favor  of  that  method.'''' 
In  this,  however,  M.  Amussat  is  egregiously  mistaken,  as  I 
shall  now  prove  by  citing  a  number  of  cases  in  favor  of  it, 
many  of  them  having  been  successfully  treated  for  years  be- 
fore any  other  method  was  ever  thought  of. 

5.  When  the  rectum  above  the  normal  anus  is  absent,  or  its 
entire  cavity  obliterated,  or  from  some  other  cause  the  natural 
anus  cannot  be  brought  in  communication  with  it,  an  artifi- 
cial anus  should  be  formed  in  the  abdomen.  [  Vide  Chapter 
on  Ahdominal  Artificial  Anus.'\ 


THE    FOUKTII    SPKUIKS    OF    MALFOUMATION.  167 


SECTION    III. 

CASES   AND  REMARKS. 

Case  LXIIL — It  is  said  by  Sclienck,  that  Jessen  saw  a 
female  infant  whose  anus  was  perfectly  formed,  but  when  a 
sound  was  introduced  into  the  rectum  the  lirm  resistance  of 
a  membrane  was  perceived,  a  short  distance  above  the  anus. 
This  membrane  was  incised  and  a  small  quantity  of  thick 
matter  was  discharged.  No  injection,  however,  could  be 
made  to  enter  the  cavity  of  the  rectum,  and  the  child  died, 
when  sixteen  days  old. 

At  the  autopsy  it  was  observed  that  the  walls  of  the 
rectum  were  adherent  at  two  points,  and  at  two  other  points 
the  rectum  was  closed  by  two  annular  membranous  septa. 
The  hmguage  of  the  author  is,  that  at  the  post-mortem,  he 
found  that  "  Rectum  intestlnum  his  lateribiis  concreveTaty 
his  orhiculari  intei'sejnebatur  memhrana.''''  {Schenck.  Ohser- 
vatioiiuin  Medicarum,  novaruin^  aiimir  ah  ilium  ^  et  monstros- 
arum.     Lih.  III.  Ohserv.   V.  ]).  38^.     Frankf.  1609.    Folia.) 

Case  LXIV. — Wagner  examined  an  infant  who  had  an 
imperforation  of  the  rectum,  but  whose  anus  was  so  well 
formed  that  he  was  enabled  to  introduce  an  ordinary  sound 
to  the  depth  of  one  inch  and  a  half,  when  it  met  with  such 
resistance  as  made  it  impossible  to  push  it  up  any  further. 
The  child  died  on  the  tenth  day  after  its  birth,  no  operation 
having  been  performed. 

At  the  autopsy  it  was  discovered  that  that  portion  of  the 
rectum  which  was  beyond  the  obstruction,  was  filled  with 
gas  and  fseces,  and  was  reflected  upon  the  superior  part  of 
the  sacrum,  to  which  it  was  firmly  attached.  {Commcr.  lit- 
ter ar.  p.  36-4.     Norimherg.     Annee  1734.) 

Case  LXY. — It  was  observed  in  a  child,  having  a  normal 
anus,  but  an  imperforate  rectum,  that  it  had  discnarged 
nothing  from  its  bowels  for  two  days  after  its  birth,  and  that 
its  abdomen  was  painfully  distended.  Attempts  were  made 
to  administer  an  enema,  but  the  fluid  returned  by  the  anus  as 
fast  as  it  was  forced  out  of  the  syringe.  Petit  now  saw  the 
child,  and  to  recognize  the  nature  of  the  defect,  introduced 
into  the  anus  a  flexible  sound  with  a  small  ball  on  the  end  of 
it.     This  instrument  could  be  easily  inserted  one  inch,  but  no 


16S  THE   FOURTH    SPECIKS    OF   MALFORMATION. 

further.  Fetit  introduced  his  finger  by  the  side  of  the  sound 
and  felt  a  rather  thin  membrane  above  the  sphincter,  which 
completely  obstructed  the  cavity  of  the  rectum,  transversely. 
By  means  of  his  pharyngotomus  inserted  up  to  the  obstruc- 
tion by  the  side  of  his  linger,  he  incised  tlie  membrane  which 
ofl'ered  but  little  resistance.  The  child  at  ouce  discharged 
the  meconium,  and  for  the  two  months  that  it  lived  afterwards, 
continued  to  discharge  its  fseces  freely.  The  child  did  not 
die  of  the  operation  nor  any  anal  disease. 

Petit  observed,  that  in  this  case  the  sphinctores  ani 
muscles  existed,  were  normal,  and  performed  their  functions 
well  ;  for  wlienever  he  inserted  his  finger  into  the  anus, 
which  he  had  frequently  done,  he  always  perceived  by  the 
touch,  the  same  sensitiveness  existing,  and  the  same  resistance 
which  are  perceived  on  introducing  the  finger  into  the  anus 
of  any  child.  {Memoire  de  VAcademie  Royale  de  Chirurgie, 
to7ne  11. 2>- ^oO.     Paris:  1781.) 

Case  LXVI. — A  child  was  witnessed  by  Engerran,  in 
which  the  anus  existed,  but  the  rectum  was  found  to  be 
imperforate.  Nothing  had  passed  its  bowels  for  four  days, 
and  it  vomited.  A  sound,  which  was  introduced,  came  in 
contact  with  a  hard  body.  This  substance  was  pierced  with 
a  sharp-pointed  triangular  probe,  and  immediately  a  large 
quantity  of  fffical  matter  was  discharged.  The  faeces,  how- 
ever, soon  gradually  accumulated  again  and  the  child  died 
one  month  afterwards. 

At  the  autopsy  it  was  observed  that  a  part  of  the  inferior 
extremity  of  the  rectum  was  indurated,  puckered,  and  drawn 
up  in  a  knot,  like  the  umbilicus  of  the  adult.  {3femoh'e  de 
VAcademie  lioyale  do  Chirurgie^  tome  11.  pp.  253,  25-1,  255. 
Paris:  1781.) 

Case  LXYII. — ^Trioen  mentions  the  case  of  a  female  child 
who  had  an  imperforation  of  the  rectum,  but  whose  anus  was 
well  formed.  On  introducing  a  sound  it  soon  met  with  firm 
resistance.  The  opposing  substance  was  incised,  but  the  child 
died  in  three  days. 

At  the  autopsy  it  w^as  discovered  that  the  rectum  M^as 
completely  obstructed  about  a,  finger' s-lreadth  above  the  anal 
orifice  by  a  membrane  which  was  ten  lines  in  thickness,  and 
almost  the  consistence  of  horn.  {Ohservationum  Medico- 
Chirurgicarurii.  J),  ^^y     Ludg.  Bat.     1743.) 

Case  LXVIII. — Smellie  relates  the  following  case  : 

"  Several  years  ago,  I  delivered  a  woman  of  her  first  child. 


TIIK   rOUIlTII    SPECIKS    OF   MALFORMATION.  169 

When  T  callcMl  next  day,  tlic  nnrso  told  itic  that  s1k\  luul  i2;ot  no 
stool,  although  she  had  given  .several  times  the  oil  and  syru]), 
and  she  was  afraid  there  was  no  ])assage  at  the  fundament,  she 
having  tried  to  introduce  a  stalk  of  parsley  and  butter.  I  in- 
spected the  part,  and  lubricating  my  tinger,  inti-oduced  tlie 
same  a  little  way  into  the  anus  ;  but  plainly  found  a  smooth 
obstruction  about  an  inch  or  less  from  the  entry. 

"  I  informed  the  father  of  the  case,  and  the  danger  the  child 
was  in,  unless  an  artificial  o]»oning  was  made,  and  advised  liini 
to  send  for  the  sui'geon  of  the  family;  on  which  Mr.  Gattaker 
was  called.  After  he  had  examined  and  found  the  same,  lie 
advised,  as  the  case  was  uncommon,  to  send  for  Mr.  Middle- 
ton.  They  were  of  the  same  ojMuion  with  me,  that  it  was 
right  to  try  to  nuike  a  perforation  immediately,  for  although 
the  success  was  uncertain,  yet  if  the  attachment  was  slight,  it 
might  succeed.  It  was  then  agreed  to  perform  the  oj^eration 
with  the  trocar.  Mr.  Middleton  sent  for  his,  as  it  was  of  a 
lai"ger  size  than  common.  Mr.  Gattaker  introduced  the  in- 
strument, and  pushed  the  point  and  sheath  through  the  adhe- 
sion in  a  line,  as  near  as  he  could  judge,  along  the  common 
course  of  the  rectnm.  Xo  meconium  appeared,  or  followed 
on  withdrawing  the  instrument.  After  this  he  introduced  a 
large  bougie,  which  went  np  a  great  way.  "We  called  next 
morning,  and  to  our  great  satisfaction  observed  some  meconi- 
nm  come  down  on  extracting  the  bougie.  Another  somewhat 
larger  was  again  introduced  ;  the  child  now  seemed  to  be  in  a 
fair  way  of  doing  well ;  but  next  day  the  nurse  showed  us  a 
small  swelling  on  the  npper  and  back  part  of  the  right  pari- 
etal bone,  which  was  turning  livid,  and  indeed  had  not  been 
observed  by  me  at  the  delivery.  On  examining  the  tumor, 
we  found  a  round  opening  in  the  bone  about  an  inch  and  a 
half  in  diameter,  and  some  of  the  brain  pushed  through  it ; 
but  this  could  not  be  reduced,  and  no  doubt  was  begun  to 
mortity,  for  the  child  died  next  day." — (A  Collection  of  Pre- 
ternatural Caf<es  and  Observations  in  Midwifery.  Vol.  III. 
Collect.  XL  VI.    p.  461.     Zondon  :  1779.) 

Cask  LXIX. — Mr.  Pinkstan,  a  surgeon  of  London  in  1751, 
reported  the  following  case,  of  this  species  of  malformation. 

"  Tuesday  evening,  May  7,  1751,  I  delivered  M.  K.  of  a 
female  child.  Next  mornino;  the  nurse  told  me  that  the  child 
had  no  stool,  although  she  had  used  all  the  common  methods 
to  procure  one  ;  besides,  she  saw  no  fault  at  the  fundament. 

"  On  examining,  I  imagined  the  same  ;  but  after  introduc- 
ing a  probe  about  half  an  inch,  I  met  with  a  firm  and  solid 
resistance. 


170  THE   FOURTH    SPECIES    OF    MALFORMATION. 

"  I  tlien  told  the  mother  the  necessity  there  was  for  per- 
forming an  oj^eration  on  the  child ;  though  not  without  ex- 
pressing some  doubt  of  its  success.  Having  obtained  her 
consent,  I  cut  about  half  an  inch  into  the  resisting  substance, 
and  finding  that  none  of  the  freces  followed,  I  enlarged  the 
external  orilice,  and  went  about  an  inch  deeper. 

"  Seeing  at  last  nothing  issue  out  but  a  little  blood,  I  intro- 
duced my  finger,  and  found  a  resistance  that  made  me  despair 
of  succeeding  in  any  further  attempt  of  that  kind,  and  I  dres- 
sed up  the  wound. 

"The  child  had  that  night  stercoracious  vomitings,  and 
these  continued  till  its  death,  which  hapj)ened  on  the  twelfth 
in  the  morning. 

"  After  much  entreaty,  I  was  permitted  to  open  the  child, 
when  I  found  the  rectum  callous  and  imperforate  as  far  as  the 
last  vertebra  of  the  loins,  which  showed  the  defect  was  abso- 
lutely incurable. 

"  In  cases,  however,  of  this  kind,  I  think  a  cure  should  al- 
ways be  attempted." — [Smellie.  ojp.  cit.  p.  464.) 

Case  LXX. — The  following  case  was  reported  on  the  20th 
of  May  1791,  by  Edward  Ford,  Esq.,  Surgeon  to  the  West- 
minster General  Dispensary. 

"  March  6th,  1791,  I  was  desired  to  see  a  male  infant,  two 
days  old,  M'ho  was  supposed  to  have  an  imperforate  rectum. 
He  appeared  to  be  a  strong  healthy  child,  well  formed  in 
every  other  i-espect,  had  taken  nourishment  the  day  before, 
and  as  he  exhibited  externally  no  marks  of  mal-conformation, 
when  examined  at  his  birth,  it  was  not  supposed  that  he 
labored  under  this  defect  till  it  was  found  that  no  evacuation 
had  taken  place  through  the  intestines,  that  he  rejected  his 
food,  and  vomited  up  every  thing  he  had  taken. 

"  When  I  saw  the  child  he  was  continually  vomiting ;  the 
matter  thrown  up  was  of  a  dark  yellow  color,  and  foetid,  and 
the  abdomen  was  tense  and  swelled  ;  in  other  respects  lie 
looked  healthy,  had  voided  his  urine  properly,  and  the  anus 
was  naturally  formed  as  far  as  regarded  its  external  appear- 
ance. 

"  I  endeavored  to  introduce  my  little  finger  through  the 
sphincter  ani  into  the  rectum,  but  found  an  uncommon 
resistance  in  the  first  attempt,  the  parts  not  admitting  of  being 
dilated  as  usual ;  and  when  this  difficulty  was  with  some 
force  overcome,  at  the  distance  of  an  inch  from  the  external 
parts,  there  was  an  obstruction  to  be  felt,  which  resisted 
every  effort  I  made  to  penetrate  it,  first  with  the  nail  of  my 
finger,  and  afterwards  with  the  blunt  end  of  a  probe. 


THE    FOUliTIi   SPECIES    OF    MALFORMATION.  171 

"Tlic  first  consideration  which  offered  to  inj  mind,  was  to 
])erforate  the  obstruction  with  a  small  trocar;  and  in  order 
to  do  tiiis  as  safely  as  i)ossible,  a  small  catheter  was  intro- 
duced through  the  urethra  into  the  bladder,  which  served  as 
a  direction  to  avoid  wounding  those  parts  in  the  operation. 
The  canula  of  the  trocar  was  then  introduced  into  the  anus, 
under  my  linger,  which  defended  the  urethra,  and  was  lixed 
as  well  as  I  could  against  the  obstructed  part  of  the  canal. 

"The  stilet  was  then  carried  up  through  the  canula,  and 
pushed  through  the  obstruction  in  a  direction  rather  back- 
wards towards  the  os  sacrum.  On  withdrawing  the  stilet  it 
was  followed  by  a  discharge  of  fiBces,  through  the  canula, 
which  continued  for  an  hour  so  as  to  form  rather  a  copious 
stool.  Upon  taking  out  the  canula,  a  bougie  was  attempted 
to  be  introduced  through  the  artificial  opening,  but  without 
effect. 

"  The  child  was  now  left  an  hour,  and  on  my  return  I 
found  his  belly  more  tense,  and  that  his  vomiting  continued. 
I  therefore  directed  several  clysters  of  oil  and  water  to  be 
thrown  up  by  means  of  a  small  pipe  which  was  fortunately 
conveyed  through  the  artificial  opening  into  the  gut.  These 
clysters  brought  off  a  considerable  quantity  of  faeces,  but  did 
not  seem  thoroughly  to  empty  the  intestinal  canal ;  so  that  I 
deemed  it  expedient  to  attempt  an  enlargement  of  the  open- 
ing, by  means  of  the  point  of  a  blunt  gorget  carried  up  into 
the  groove  of  a  common  director.  A  farther  discharge  of 
faeces  ensued  ;  and  the  child  was  then  put  into  a  warm  bath, 
and  castor  oil  was  afterwards  administered  by  the  moutii. 
llTotwithstanding  these  remedies,  the  vomiting  continued,  the 
child  became  convulsed  and  died  in  the  course  of  the  follow- 
ing night.  Upon  opening  the  body  the  next  morning,  I  found 
marks  of  considerable  inflammation  in  the  intestines,  princi- 
pally in  the  large  ones,  which  were  inflamed  to  a  great  degree. 
There  was  no  obstruction,  however,  to  be  found  in  any  part 
of  tiie  intestinal  canal,  except  that  in  the  rectum. 

"  The  drawing  which  accompanies  this  paper  will  show  the 
manner  in  which  the  intestine  terminated  in  a  blind  pouch, 
at  the  distance  of  an  inch  from  the  anus,  in  the  hollow  of  the 
OS  sacrum.  The  space  between  the  intestine  and  the  anus 
was  lined  with  an  elastic  ligamentous  substance,  which 
would  probably  have  produced  much  inconvenience  to  the 
patient  in  retaining  his  stools,  had  the  operation  performed, 
protracted  his  existence."  \_Vlde  PlateYl^ Figure  2.]  {Med- 
ical Facts  and  Ohservatlons.    Vol.  I.  p.  102.    London,  1791.) 

Case   LXXI. — ^William  Adair,  Esq.,  Surgeon  General  to 


172  THE   FOURTH    SPECIES    OF   MALFORMATION. 

tlie  garrison  of  Gibraltar,  rej^orted  the  following  interesting 
case,  on  the  3rd  of  November,  1792. 

"  On  the  7th  of  August,  1792,  I  was  called  to  a  child  of  an 
officer  of  this  garrison,  which  had  been  born  thirty  hours 
without  having  had  any  evacuation  by  the  anus.  Upon  an 
examination,  I  found  a  j)assage  of  about  two  inches  at  the 
usual  exit  of  the  rectum,  but  which  beyond  this  was  imper- 
vious. There  was  an  appearance  as  if  nature  had  made  an 
attempt  at  another  passage ;  for  at  tlie  end  of  the  posterior 
perinaeum,  near  the  os  coccygis,  was  a  small  sinus  of  about 
half  an  inch  in  a  direction  towards  the  rectum.  In  both  these 
blind  passages  the  cuticle  w^as  equally  strong  as  on  any  other 
part  of  the  body.  Tliere  could  be  no  hesitation  from  which 
of  the  two  we  ought  to  attempt  a  communication  with  the 
intestinal  canal,  and,  therefore,  after  examining  with  a  jjretty 
thick  bougie,  the  former  and  most  natural  of  these  passages, 
I  took  a  middling-sized  trocar,  and  introduced  it  with  the  point 
within  the  canula,  till  it  reached  the  end  ;  then  pushing  it 
beyond  the  canula,  and  finding  that  not  sufficient,  I  pushed 
the  trocar  forward,  till  it  had  completely  overcome  the  resis- 
tance. I  then  left  the  canula  in,  and  drawing  out  the  trocar, 
observed  the  point  of  it  tinged  with  meconium.  This  latter 
circumstance  seemed  to  be  a  very  favorable  appearance  :  but 
after  waiting  some  time  nothing  came  away  through  the  can- 
ula, nor  when  this  was  removed  did  anything  follow  but  a 
few  drops  of  blood.  I  now  introduced  a  proper-sized  bougie, 
which  was  suffered  to  remain  for  some  hours  ;  but  when  this 
was  drawn  out,  nothing  followed  but  a  few  drops  of  blood.  A 
sponge  tent  of  a  proper  size  was  also  pushed  up,  and  left  in 
for  several  hours ;  but  though  it  extended  the  passage  more 
considerably  than  the  bougie  had  done,  no  stools  followed  on 
its  being  taken  out.  The  parts  after  this  were  left  at  rest 
until  next  day,  only  a  little  warm  milk  was  ordered  to  be 
thrown  up  the  passage  ;  and  as  the  child  (though  its  belly  was 
preternaturally  full,  but  not  hard,  and  it  had  now  been  fifty- 
eight  hours  \vithout  any  passage  by  stool,  which  in  this  cli- 
mate, and  in  the  month  of  August,  Avas  very  unfavorable,) 
still  seemed  strong  and  hearty,  we  introduced  another  pretty 
thick  bougie  up  the  passage,  and  left  it  there  for  twenty-four 
hours.  This,  when  withdrawn  was  followed  by  a  copious  black 
stool,  and  that  was  succeeded  by  eight  more  in  the  course 
of  twelve  hours.  Xext  day  the  evacuations  were  very  fre- 
quent, to  the  amount  of  sixteen  stools,  after  which  they  dimin- 
ished in  number,  and  became  of  the  natural  color.  Tlie  cliild 
now  appeared  to  be  going  on  very  well,  liut  soon  fell  oft';  the 
stools   became   sometimes   dark,    and   sometimes   yellow ;    a 


THE   FOURTH    SPECIES   OF   MALFORMATION.  173 

fevorislincss  succeeded  ;  tlie  ])elly  coiitimied  distended  till  two 
days  betorc  it  died,  and  then  became  suiullei".  The  child 
lived  only  fifteen  days. 

I  had  no  o])portunity  of  examining  the  body,  so  that  the 
cause  of  death  cannot  be  ascertained  ;  but  the  history  of  the 
case  leads  me  to  consider  it  as  not  immediately  connected 
Avitli  the  consequences  of  the  operation.  The  child  might 
have  been  defective  in  other  respects  essentially  coniu'cted 
with  the  vital  organs.  The  operation  succeeded  perfectly  in 
giving  a  passage  for  the  contents  of  the  bowels  ;  and  so  far 
this  case  is  deserving  of  notice,  as  it  may  give  some  informa- 
tion to  others  who  have  this  operation  to  perform  under  simi- 
lar circumstances.  It  proves  that  although  the  contents  do 
not  Immediately  follow  the  instrument  nor  even  the  bougie,  it 
is  not  to  discourage  the  surgeon  from  future  attempts,  as  per- 
severing in  the  use  of  the  bougie  may  be  attended  by  the 
wished  for  success."  {^Medical  Facts  and  Ohservatiois,  Yol. 
IV.,  ■:p.'-2n. London:  1793.) 

Case  LXXII. — ^Tlie  following  interesting  case  of  imperfor- 
ate rectum,  above  a  well  formed  anus,  was  reported  by  Mr. 
William  Chamberlaine,  of  London,  on  the  13tli  of  March, 
1797. 

"  I  was  called  to  attend  the  labor  of  Mrs.  Ashmore,  No.  15 
King  Street,  Compton  Street.  She  had  a  good  natural  labor, 
and  was  safely  delivered  of  a  male  child.  On  my  visiting 
the  next  day,  the  nurse  informed  me  the  child  had  had  no 
evacuation  either  by  stool  or  urine,  and  that  it  appeared  very 
uneasy.  I  found  the  pulse  feverish,  and  a  great  degree  of 
tension  and  hardness  of  the  abdomen. 

"  On  examining  the  anus,  I  found  it  in  a  natural  state  ;  how- 
ever, supposing  it  possible  there  might  be  an  obstruction 
higher  up,  I  introduced  a  probe  into  the  rectum  and  found  a 
firm  resistance  at  the  distance  of  somewhat  less  than  an  inch 
and  a  half.  Withdrawing  the  probe,  I  then  introduced  a 
very  small  glyster-pipe,  well  oiled,  which  stopped  at  the  very 
same  place  ;  then  examining  the  obstruction  by  means  of  the 
probe,  the  glyster-pipe  serving  as  a  canula  or  director,  I  had 
not  the  satisfaction  to  find  anything  like  reaction,  or  any  sen- 
sation as  if  the  faeces  were  forcing  down  sorae  thin  obstructing 
membrane.  However,  as  the  case  was  desperate,  and  a  most 
miserable  and  perliajis  lingering  death  was  inevitable,  unless 
something  should  be  done,  I  determined  at  all  hazards,  to 
attempt  a  perforation.  Having  represented  the  case  and  its 
consequences  to  the  parents,  and  obtained  their  permission,  I 
determined  to  perform  the  operation  with  a  small  trocar ;  and 


174  THE   FOURTH   SPECIES   OF   MALFORMATION. 

introducing  the  canula  first,  well  oiled  as  liigh  as  the  obstruc- 
tion, I  pushed  the  perforator  through  the  obstructing  sub- 
stance until  I  found  no  farther  resistance ;  then  withdrawing 
it  and  the  canula  together,  I  had  the  pleasure  to  see  the 
instrument  followed  by  a  very  copious  discharge  of  the  meco- 
nium slightly  tinged  with  blood.  I  then  thought  it  advisable 
to  inject  a  common  glyster  ;  the  pipe,  in  passing,  stopped  at 
the  place  where  the  obstruction  had  been,  but  the  resistance 
was  soon  overcome,  and  a  very  mdoerate  degree  of  force 
enabled  me  to  get  it  all  the  way  up.  None  of  the  glyster  was 
returned,  and  the  child  seemed  perfectly  easy.  On  my 
return,  however,  in  about  two  hours,  I  found  we  had  still 
another  difficulty  to  combat  witli.  He  had  not  made  urine, 
and  in  consequence  of  this,  convulsions,  shrieking,  fever,  ten- 
sion of  the  abdomen,  and  other  alarming  occurrences,  had 
come  on.     I  took  a  coach  and  went  to  Evans's,  but  could  not 

fet  a  catheter  of  a  size  small  enough  for  a  new  born  infant, 
took  with  me,  however,  one  of  the  smallest  gum  elastic 
catheters  I  could  lind  ;  but  even  this  on  trial,  was  too  large, 
and  would  not  enter  the  urethra.  No  time  was  to  be  lost ; 
but  having  no  proper  instrument,  I  bent  my  probe  into  the 
form  of  a  catheter,  and  having,  previously  to  my  attempt  to 
introduce  the  hollow  bougie,  divided  with  a  lancet  the  small 
membrane  that  closed  up  the  exrernal  orifice  of  the  urethra, 
I  passed  the  probe  without  difficulty,  as  far  as  the  neck  of  the 
bladder  ;  having  got  thus  far,  its  passage  seemed  opposed  by 
some  obstructing  substance  ;  nevertheless,  by  a  little  persever- 
ance, and  gentle  management  of  the  probe,  I  was  fortunate 
enough  to  find  the  probe  at  last  move  forwards,  until  I  could 
perceive  it  to  be  fairly  in  the  bladder,  and  the  urine  making 
its  appearance  at  the  external  orifice  of  the  urethra.  I  then 
withdrew  the  probe,  which  was  followed  by  a  j^lentiful  dis- 
charge of  urine,  and  the  child  became  for  a  time  easier. 

"  Next  day,  however,  a  message  was  sent  to  me  early,  that 
the  child  was  worse  ;  I  found  all  the  symptoms  of  the  preced- 
ing day  much  aggravated,  with  inflammation  (which  the 
nurse  mistook  for  mortification)  of  the  abdomen ;  I  ordered 
the  warm  bath,  fomentations,  and  emollient  glysters,  to  be 
prepared,  and  passed  the  probe  as  the  day  before,  with  the 
same  success.  By  the  help  of  these  aj)plications,  and  a  few 
aperient  and  carminative  medicines,  the  child  recovered,  and 
is  now  perfectly  well."  {Memoirs  of  the  Medical  Society 
of  London.  Vol.,  V.  Art.  XXIII.,  p.  206.  London:  1799.) 

Case  LXXIII. — Mr.  Copeland,  assistant  surgeon  to  the 
Westminster  General  Dispensary,  had   the  good  fortune  to 


THE   FOURTH    SPECIES    OF   MALFORMATION.  175 

treat  with  success  two  cases  of  tliis  species  of  niullunuutiun  ; 
one  of  which  lie  reports  as  follows  : 

"I  was  desired  by  the  late  Dr.  Tliynne  to  see  a  male  child, 
wlio  was  born  with  an  ini|)erforate  amis,  [recturii.)  The  form 
of  the  amis  was  perfect  externally,  but  on  introducing  a  bou- 
gie it  was  stopped  in  its  progress  about  an  inch  from  the  ex- 
ternal aj)erture.     The  abdomen  was  very  tumid. 

"  After  some  consideration,  I  passed  a  flat  trocar  on  my 
finger  into  the  anus,  with  the  point  drawn  into  the  canula ; 
and  when  it  would  pass  no  further,  I  projected  the  point 
through  the  impediment;  no  fluid  followed;  but  when  the 
instrument  was  withdrawn,  I  thought  I  felt  the  tumid  ex- 
tremity of  the  gut ;  and  b}^  forcing  it  on  I  came  in  contact 
with  the  OS  sacrum.  I  had  then  no  great  hope  of  the  recovery 
of  my  little  patient,  and  still  less  on  the  follow^ing  day  ;  but 
desired,  that  if  any  faecal  evacuation  took  place,  I  might  be 
sent  for.  I  was  called  on  the  fourth  day,  and  found  that  a 
considerable  alvine  evacuation  had  passed,  and  the  belly 
much  gone  down.  When  1  examined  with  iny  little  finger,  I 
found  the  extremity  of  the  gut  with  a  small  perforation  so 
very  high  up  in  the  pelvis,  that  I  was  fearful  to  introduce  an 
instrument  to  enlarge  the  opening,  if  it  could  with  safety  be 
avoided. 

""The  next  day,  the  fifth,  the  child  had  taken  some  castor 
oil;  the  surrounding  parts  were  considerably  swelled  and  in- 
flamed, and  the  abdomen  again  tense,  though  some  faecal 
evacuation  had  passed ;  he  seemed  easy,  and  had  slept. 

"The  sixth  day,  but  little  of  the  contents  of  the  abdomen 
had  passed,  and  the  child  was  still  swelled  and  uneasy,  until 
the  bowels  were  evacuated  by  castor  oil.  There  was  a  con- 
siderable purulent  discharge  from  the  anus.  I  had  a  great 
objection  to  the  repeated  introduction  of  instruments,  or  my 
finger,  lest  an  interruption  should  be  given  to  the  adhesions 
which  I  hoped  were  forming  between  the  gut  and  tJie  sur- 
rounding parts  ;  but  so  great  w^as  the  difiiculty  of  passing  the 
fifices,  that  the  following  day  I  introduced  a  large  elastic 
catheter,  and  the  fseces  flowed  freely  through  it.  The  catheter 
was  used  as  often  as  was  necessary,  for  a  considerable  time, 
and  to  this  I  chiefly  attribute  the  recovery  of  my  patient,  for, 
during  its  use,  the  purulent  discharge  ceased,  and  the  gut  de- 
scended nearer  to  the  anus. 

"When,  after  some  time,  I  introduced  my  finger,  the  aper- 
ture at  the  extremity  of  the  gut  was  felt,  hard  and  contracted 
close  to  the  anus,  it  was  dilated  by  the  use  of  bougies,  which 
were  continued  for  some  time,  and  the  child  performs  his 
functions  with  but  little  interrui^tion,  and  is  otherwise  in  per- 


176  THE   FOURTH    SPECIES    OF   IVIALFOEMATION. 

feet  hecaltli." — {Ohservations  on  the  Principal  Diseases  of  the 
Rectum  and  Anus.    p.  174.     London  :  1814.) 

Case  LXXIV. — A  case  is  recorded  by  Mr.  Wayte,  in  whicli 
tlie  membranous  septum  was  felt  by  the  finger  above  an  incli 
from  the  verge  of  the  anus.  It  was  pierced  with  a  pointed 
probe,  which  was  followed  by  a  hydrocele  trocar,  and  after- 
wards by  a  bougie  of  large  dimensions.  On  withdrawing  the 
latter,  much  meconium  mixed  with  fiBces  escaped,  and  con- 
tinued to  be  frequently  discharged.  In  a  week,  however,  the 
opening  closed,  and  a  fresh  puncture  was  made,  which  was 
maintained  by  the  frequent  introduction  of  bougies.  Tlie 
child  proceeded  tolerably  well,  until  the  end  of  another  week, 
when  the  passage  was  again  much  contracted,  and  the  abdo- 
men proportionally  distended.  On  the  twentieth  day  from 
birth,  a  full-sized  trocar  was  used  for  restoring  the  opening, 
which,  however,  again  had  a  tendency  to  close,  but  was  after- 
wards dilated  by  introducing  twice  a  day  bougies  which  were 
increased  in  size,  until  a  rectum  bougie  of  middle  size  could 
be  jjassed.  The  boy  now  rapidly  improved,  and  every  liope 
of  a  perfect  recovery  was  entertained,  but  disease  of  the  os 
coccygis  ensued,  and  at  the  end  of  six  months  the  little  pa- 
tient died  hectic.  [Edhiburgh  Medical  and  SurgicalJournal, 
Vol.  XVIL,  1).  232.     April:  1821.) 

Case  LXXV. — A.  Copeland  Hutchison,  Esq.,  relates  the 
case  of  an  infant  which  presented  a  normal  anus,  but  some 
distance  above,  the  rectum  was  found  impervious.  Tlie  oper- 
ation in  this  instance  failed,  and  it  is  especially  on  this  account 
that  the  case  is  worthy  of  notice. 

"I  was  called  upon  by  Mr.  Cullen,  of  Sherness,  to  operate 

on  an  infant  son  of  Mr.  H ,  at  Queensborough.     The  child 

was  otherwise  well  formed,  and  the  anus  marked  so  distinctly 
that  a  small  bougie  was  passed  upwards  in  the  apparently 
natural  passage  for  nearly  half  an  inch,  when  it  met  with  a 
total  obstruction  ;  even  the  smallest  probe  could  not  pass ;  in 
fact,  there  was  a  total  closure  of  the  gut  above  the  external 
well-marked  anus. 

"In  the  presence  of  my  friend,  Mr.  Cullen,  I  made  an  in- 
cision of  proper  length  and  depth,  wnth  the^ scalpel,  and  then 
introduced  a  small  sized  trocar  with  great  caution  for  fully 
three  inclies ;  but  no  meconium,  only  a  very  little  blood  es- 
caped on  withdrawing  the  stilette. 

"The  patient  died  in  a  few  hours  afterwards;  and  on  ex- 
amination after  death  we  found,  by  the  introduction  of  a  bou- 
gie, that  the  gut  was  grazed  by  the  cutting  instrument,  which 


TIIK    KOURTII    SPKCIKS    OK    M  AM'oKM  ATK  ..V.  177 

had   it   ]uMietrnt('(l,   there   was   eveiy  chance   tliat   tlic   child 
would  have  survived."     {Op.  cit.  p-  ^Ti.j 

Cask  LXXVL— D.  O.  Edwards.  Esq.,  of  Westminster, 
Eiii;'laiid,  reported,  on  the  28th  of  Jaiiuaiy,  1S.^)0,  the  follow- 
iu^i'  ease  of  an  infant  havin<jj  a  normal  anus  with  an  ini])erf  >- 
ration  of  the  rectum  some  distance  ahove. 

"Ann  Aldridge,  residinii;  in  Castle  Lane,  Westminster,  a 
delicate  woman,  about  thii-ty-seven  years  of  age,  was  at  the 
full  ])eriod  of  gestation  delivered  hy  natural  efforts,  on  the 
17th  instant,  of  a  male,  her  sixth  child.  The  two  preceding 
children  were  still-born,  and  the  mother  had  suffered  nnich 
from  grief  and  anxiety,  having  been  deserted  by  her  husband, 
and  obli<;:ed  to  maintain  the  surviving  children  bv  her  exer- 
tions  as  a  laundress.  The  infant  was  full  o;rown,  havino: 
nothing  jDeculiar  in  its  external  form,  except  the  continuance 
of  the  sagittal  suture  downwards  to  the  nose.  The  integu- 
ments were  rugose  and  sodden,  plaiidy  indicating  a  decrease 
of  substance  since  the  consummation  of  its  growth.  Its  cries, 
respiration,  and  other  muscular  efforts,  were  unusually  feeble. 

"  On  inquiry,  twenty-four  hours  after  birth,  it  appeared  that 
no  discharge  whatever  had  taken  place  ])er  anum;  the  infant 
seemed  to  have  no  power  of  suckling,  and  rejected  every  kind 
of  aliment.  The  abdomen  was  distended  and  painful  on  pres- 
sure, the  lower  limbs  rigidly  contracted  on  the  pelvis,  respira- 
tion difficult,  and  a  constant  moaning  existed.  The  form  of 
tiie  bladder  also,  notwithstanding  a  discharge  of  urine  had 
taken  place,  was  distinctly  manifest  in  the  hypogastrium. 
The  anus  was  apparently  well  formed,  in  its  projjer  site,  and 
of  the  usual  size,  and  during  the  strenuous  attempts  at  dejec- 
tion, which  the  little  sufferer  was  constantly  makiuir,  the 
retractive  efforts  of  the  levator  ani  were  particularly  evident. 

"  The  introduction  of  a  bougie  detected  an  obstruction 
about  an  inch  above  the  external  orifice,  and  which  the  finger 
ascertained  to  be  impeneti-ably  strong  and  fibrous.  At  each 
endeavor  to  expel  the  excrement,  an  impression  was  commu- 
nicated to  the  finger  similar  to  the  pressure  of  a  quantity  of 
impending  fluid. 

"•  Having  consulted  my  friends,  Messrs.  Chapman,  Weight, 
and  Blakeney,  the  penetration  of  this  adventitious  membrane 
was  considered  to  be  the  most  rational  and  indeed  only  pro- 
bable means  of  saving  the  child  from  imminent  death.  An 
incision  was  therefore  made,  forty-eight  houi's  after  birth, 
from  the  anus  to  the  coccyx,  and  as  far  up  as  the  cul-de-sac, 
which  formed  the  obstruction.  A  sharp-pointed  bistoury  w^as 
then  introduced,  shielded  by  the  index  finger,  and  three 
12 


178  TnE    FOURTH  SPECIES    OF   MALFORMATION. 

incisions,  commencing  at  one  point,  and  directed  towards  the 
sacrum,  made  completely  through  the  membrane;  no  fluid 
esca{)ed ;  the  knife  was  withdrawn,  and  the  finger  again 
passed  up,  but  no  indication  of  the  situation  of  the  rectum 
could  be  found,  and  the  near  neighborhood  of  the  perito- 
neum, bladder,  vessels,  etc.,  was  tangibly  evident.  It  was 
thought  prudent,  for  these  reasons,  to  desist  from  the  further 
use  of  the  knife,  and  the  usual  palliatives  were  resorted  to 
during  the  remainder  of  the  ciiild's  existence,  which  termi- 
nated on  the  following  day,  with  all  the  symptoms  of  strangu- 
lation. 

"  AibUrpsy  six  hours  after  death — Conducted  in  the  pre- 
sence of  Messrs.  AVeight,  Chapman,  Blakeney,  and  Jenkins. 
Abdomen  much  swollen,  and  slightly  discolored.  On  making 
the  first  incision,  a  small  quantity  of  dark-colored  blood 
escaped,  and  the  alimentary  canal  was  found  distended  to  the 
utmost.  The  liver  was  of  ordiiuvry  size,  color,  and  consistence  ; 
the  gall-bladder  elongated,  deeply  imbedded  in  the  paren- 
chyma of  the  liver,  peculiarly  curved  near  the  fundus,  and 
filled  M'ith  dark-colored  bile.  The  stomach  and  small  intes- 
tines were  filled  with  flatus,  and  contained  mucus  mixed 
with  bile.  Into  the  coecal  portion  of  tlie  ileum,  a  quantity  of 
meconium  had  escaped  through  the  ileo-coecal  valve,  but 
which  was  of  perfectly  natui'al  formation.  Nearly  the  entire 
peritoneum  was  inflamed,  and  particularly  tiiat  which  envelops 
the  large  intestines.  The  ccecum,  colon,  and  rectum,  were 
completely  filled  with  thick  and  viscid  meconium.  The  mus- 
cular and  mucous  tunics  were  pretty  healthy  in  the  stomach, 
duodenum,  and  jejunum,  but  a  large  portion  of  ileum  was  in 
a  p-aiio-renous  state,  and  all  the  laro;e  entrails  indicated  a  state 
of  intense  inflammation.  Sigmoid  flexure  remarkablj^  large, 
vith  a  long  mesenteric  attachment.  The  reditui  termhiated 
vn  a  cul-de-sac  at  the  nnddle  of  the  sacrum,,  having  a  meso-rec- 
tuni  ill  its  whole  length,  and  a  complete  peritoneal  covering  / 
the  mucous  lining  a'ul  inuscular  tissue  equally  contributed  to 
form  the  sac.  Tne  peritoneum  was  reflected  laterally  and 
dov;nward,  from  tlie  meso-rectum  to  the  sacrum  and  sides  of 
the  pelvis,  and  wa^^,  as  usual,  continued  forwards  over  the 
bladder,  giving  a  covering  in  its  passage  to  the  tliird  portion 
of  the  rectum,  which  was  thus  completely  detached  from  the 
main  gut.  This  membrane  being  raised,  the  recto-vesical 
fascia  was  seen  passing  backwards  from  the  neck  of  the  blad- 
der, and  ('ompletely  closing  up  tlie  inferior  opening  <»f  the 
pelvis.  Under  this,  the  levatores  ani  lay,  stretching  from  the 
sides  of  the  bhidder  directly  backwards  to  the  sacrum,  and 
becoming  blended   with  the  muscular  fibres  of  the  spliiucLui* 


THE   FOURTir    SPECIES   OF    MALFOIlMAnON.  17J> 

and  tlie  loiinitiuliiial  lihrcs,  whicli  constituted  tlio  insulated 
anus.  The  Sj)hincter  was  iicrfectly  well  fornied,  and  attached, 
as  usual,  to  the  coccyx  and  centrum  tcndiiKJsuni  perinei  ;  its 
fibres  were  intimately  connected  with  th'ose  of  the  levator 
ani,  and  contrihuted  to  form  the  adventitious  harrier. 

"It  is  evident  from  the  dissection,  that  the  cavity  of  the 
peritoneum  intervened  between  the  blind  pouch  of  the  rectuin 
and  that  of  the  anus,  and  consequently  no  operation  could 
have  availed  ;  a  distance,  too,  of  half  an  inch  existed  between 
the  termination  of  the  rectum  and  that  of  the  anus,  'ihe 
bladder,  urethra,  and  their  ap])eudages,  were  perfectly  well 
formed,  and  in  their  proper  position;  tlie  peh'ic  arteries 
obeyed  the  ordinaiy  laws  of  their  distribution,  regardless  of 
the  disorder  extant  around  them.  In  the  thorax,  the  viscera 
and  their  coverings  were  perfectly  natural,  and,  indeed,  the 
whole  economy  seemed  perfectly  well  adapted  to  sustain  the 
development  of  life,  but  for  the  fatal  lusus  just  described. 

"One  of  the  three  incisions  had  penetrated  the  cavity  of 
the  peritoneum,  hut  no  intestine  had  been  wounded."  {Lou- 
don Lancet.   Vol.  I.  Feh.  6,  1830.  p.  637.) 

Case  LXXYII. — M.  de  Lens  related  the  following  case  to 
the  "  Medical  Society  of  Paris'''  in  February,  1835. 

"In  a  young  child  which  M.  de  Lens  saw  in  company  with 
M.  Moreau,  and  which  had  not  passed  meconium  for  twenty- 
four  hours  after  birth  ;  the  examination  of  the  anus,  showed 
an  imperforation  of  the  rectum  several  lines  above  the  ana! 
orifice.  The  cul-de-sac  could  be  very  clearly  perceived  with 
the  finc-er.  When  the  fino^er  was  introduced  to  the  bottom 
of  this  external  cul-de-sac  no  impulsion  was  perceived. 

"The  operation  was  performed  with  the  trocar,  and  a  con- 
siderable quantity  of  faecal  matter  followed  by  the  canula. 
A  tent  of  charpie  was  introduced  into  the  opening,  but  grave 
symptoms  jjresently  manifested  themselves,  and  the  child  died 
next  day. 

"No autopsy  was  had."  {Revue  MSdicale  de  Pari^.  Mai. 
1835.  p.  285.) 

Case  LXXVIII. — M.  Sandras  also  related  to  the  "  Jledical 
Society  of  Paris^"*  at  the  same  time,  a  somewhat  similar  case 
to  that  of  M.  de  Lens.  In  this  case  the  following  peculiarity 
presented  itself:  Whenever  the  child  cried,  the  anus  formed 
a  clearly  marked  protuberance.  M.  Sandras  performed  the 
operation  with  a  bistoury,  which  he  conducted  upon  a  director 
to  the  extent  of  about  three  lines.  After  the  passage  of  the 
meconium,  he  uiade  the  usual  dressings  adopted  in  the  opera- 


180  THE   FOURTH    SPECIES    OF   MALFORMATION. 

tion  for  fissure  of  the  anus,  and  the  little  patient  was  cured. 
{Log.  cit.) 

Case  LXXIX. — M.  Forget  reports  the  following  case : 
Being  called  to  an  infant  affected  with  an  iniperforation  of 
the  anus,  he  found  the  rectum  obliterated  about  ten  lines 
from  the  anal  orifice.  The  obstacle  presented  to  the  finger 
the  form  of  a  cul-de-sac,  resisting  and  corrugated  as  if  ]>ro- 
duced  by  a  ligature,  or  an  interruption  of  the  intestine.  The 
cries  of  the  child  and  the  pressure  upon  the  abdomen  gave  no 
sign  of  fluctuation  to  the  finger.  M.  Forget  considered  the 
case  a  grave  one  :  as  the  condition  of  the  child  was  not  imme- 
diately dangerous,  notwithstanding  the  tension  of  the  abdo- 
men, vomiting,  &c.,  he  advised  the  friends  to  take  the  child 
to  M.  Roux,  who  would  decide  the  kind  of  operation  to  be 
performed,  not  daring  himself  to  make  a  puncture  through  an 
obstacle  whose  limits  were  not  at  all  indicated.  The  parents, 
frightened  at  the  idea  of  an  operation,  removed  their  child, 
without  being  Avilling  to  show  it  to  any  one,  not  even  to  the 
usual  attending  physician,  who  wished  to  watch  the  state  of 
the  obstacle.  It  w^as  not  till  ten  days  after,  that  another 
physician,  having  asked  to  see  the  child,  recognized  a  fluctu- 
ating tumor  in  the  anus,  which  he  immediately  incised  with 
a  lancet,  and  the  child  was  saved.  {Revue  Medicals  de  Paris. 
Mai.  1835.  2^'  283.) 

Case  LXXX. — M.  Billard  reports  the  following  case  of 
imperforation  of  the  rectum,  in  which  the  anal  orifice 
existed. 

"  Leblond,  aged  one  day,  of  a  robust  constitution,  entered 
the  infirmary  of  the  Ilosjpice  des  Enfans  Trouves  on  the  luth 
of  July.  To  the  night  of  the  eleventh,  he  liad  passed  no 
meconium  ;  yet  the  orifice  of  the  anus  appeared  free  ;  the 
abdomen  had  become  swollen  and  very  painful ;  the  respira- 
ration  was  difficult ;  the  extremities  cold ;  the  pulse  small  ; 
the  cries  were  without  intermission.  Towards  evening,  the 
child  after  having  throw^n  up  a  quantity  of  yellow  mucus, 
vomited  the  meconium. 

"  It  was  placed  in  a  bath  for  half  an  hour  without  having 
any  evacuation.  The  anal  opening  appeared  to  exist  exter- 
nally, and  a  catheter  could  be  introduced  to  the  depth  of  one 
inch,  but  then  met  with  an  insurmountable  resistance.  I 
caused  a  suppository  of  soap  to  be  passed  in  the  rectum,  and 
let  it  remain  half  an  hour  without  any  evacuation.  I  then 
passed  a  bistoury,  the  point  of  which  was  directed  by  means 
of  a  grooved  probe  in  the  direction  of  the  sacrum  ;   the  edge 


THE    FOUIiTII    SPECIKS    OF    MALFORMATION.  181 

of  the  iiistrninoiit  turned  backward,  and  tlie  hack  .if  it 
forward.  Tlie  feelinii;  that  the  resistance  was  overcome, 
indicated  that  the  peribration  had  hcen  made.  I  withfh-ew 
the  instrument,  tlie  point  of  which  was  covered  witli  meco- 
nium ;  a  small  quantity  of  blood  flowed.  An  injection  was 
then  o-iven  which  was  soon  returned,  brin<j;in<r  with  it  some 
g-rumous  blood.  The  child  was  again  placed  in  the  })ath, 
without  experiencing  any  relief.  The  cry  became  more 
feeble  ;  the  abdomen  swelled  more  and  more  ;  the  respiration 
was  (juick  and  suflfocating.  Death  took  place  about  the 
middle  of  the  night, 

"  Pod  mortem  Examination. — Mouth  and  oesophagus 
healthy  ;  the  stomach  contained  some  meconium  ;  it  was  also 
found  in  the  small  intestines,  which  were  distended  M'ith  gas. 
The  large  intestines  were  considerably  dilated  by  thick  meco- 
nium ;  the  dilatation  commenced  at  the  cjECum.  The  rectum 
terminated  by  a  cul-de-sac  the  extremity  of  which  was 
(Corrugated  ;  it  adhered  to  the  neck  of  the  bladder,  and  did 
not  descend  to  the  anal  orifice  in  the  skni.  The  incision 
made  in  the  cul-de-sac  by  the  bistoury  was  found  filled  with 
a  i-ecently  formed  clot  of  blood,  which  seemed  to  havu 
resulted  from  a  haiinorrhage  from  the  ha^morrhoidal  arterie-s. 
All  the  organs  of  the  abdomen  were  perfectl}^  healthy. 

The  lungs  were  goi-ged  wnth  blood  at  their  posterior 
border ;  the  foetal  openings  were  free  ;  the  sinuses  of  the 
cranium  were  filled  M'ith  blood."  {A  Treatise  on  the  Diseases 
of  Infants.  English  Translation,  by  James  Stewart^  M.  D. 
p.  280.     mw  York :  1839.) 

Case  LXXXI. — The  following  case  of  imperforate  rectum 
accompanied  with  a  normal  anus,  occurred  in  the  practice  of 
Dr.  James  Stewart  of  the  city  of  New  York,  who  reports  it 
in  the  Appendix  of  liis  English  version  of  Billard  on  tlie 
Diseases  of  Infants.  A  narrative  of  the  same  case  was  read 
to  the  "  Kappa  Lambda  Society  of  JYeio  York''^  by  the 
operator,  Ricliard  K.  Hoffman,  M.  D.  In  this  instance  Dr. 
Hoffman  operated  with  a  trocar  used  for  paracentesis,  with 
complete  success. 

"The  lady  of  Mr.  J.  P ,  of  this  city,  (Isew  York,)  was 

delivered,  on  the  12th  of  June,  1839,  of  a  male  child.  He 
was  to  all  appearance  in  perfect  health,  and  it  was  not  until 
the  next  day  that  any  disordered  state  of  liis  system  was 
manifested.  The  nurse  then  stated  that  he  had  passed  no 
meconium  and  appeared  to  be  much  distressed  with  nausea. 
Laxative  enemata  were  directed  to  be  used  ;  a  teaspoonful  of 
castor   oil   had   previously    been   given   by   the    nurse   and 


183  THE   FOUKTH    SPECIES    OF   MALFORMATION. 

rejected  ;  on  making  a  visit  in  tlie  evening  of  the  same  day, 
it  was  ascertained  that  great  difficulty  liad  been  experienced 
in  giving  the  injection.  Tlie  nausea  and  vomiting  liad 
increased,  no  meconium  had  been  voided  ;  and  on  examining 
the  abdomen  it  was  found  swelled  and  tense.  Suspecting 
that  there  existed  some  obstruction  in  the  intestinal  canal,  an 
examination  was  made  of  the  condition  of  the  rectum  ;  the 
anus  was  found  perfect,  but  an  obliteration  was  discovered 
about  three  quarters  of  an  inch  from  the  sphincter ;  various- 
sized  elastic  bougies  were  introduced  to  ascertain  the  exist- 
ence of  a  passage  and  to  dilate  it  if  one  could  be  found,  but 
not  the  slightest  opening  could  be  detected,  even  with  a 
small  probe. 

On  ascertaining  this  condition  of  the  part,  the  nature  of 
the  malformation  was  explained  to  the  parents  and  its  inevit- 
able consequence,  the  death  of  the  child,  announced,  unless 
relieved  by  an  artificial  opening,  which  at  the  same  time  it 
was  told  them  was  uncertain,  from  the  impossibility  of  ascer- 
taining the  extent  of  the  obliteration.  Dr.  Richard  K. 
Hoffman  was  requested  to  visit  the  patient;  who  upon  a 
careful  examination,  coincided  in  the  opinion  previously 
expressed,  and  recommended  an  operation,  as  affording  the 
only  chance  of  saving  the  child's  life.  Having  obtained  the 
consent  of  the  parents,  he  immediately  introduced  a  common 
trocar  into  the  rectum,  and  passed  np  to  the  obliterated 
portion  ;  this  was  found  to  be  tough  membrane,  and  some 
force  was  required  to  pass  the  instrument  through.  The 
meconium  immediately  flowed  out  on  withdrawing  the 
instrument,  accompanied  with  a  quantity  of  thick  purulent 
fluid.  Injections  were  given,  and  the  bowels  kept  open  by 
their  use.  He  continued  to  liave  offensive  discharges  for  a 
week  afterwards.  At  the  time  of  writing  this  (July  26th,)  he 
is  perfectly  well  and  in  a  thriving  condition."  {A  Treatise 
on  the  Diseases  of  Infants,  hj  C.  M.  Billard.  English 
Version,  hj  James  Stewart,  M.  D.  p.  oil.  New  York  :  1839. 
Also — New  York  Journal  of  Medicine  and  Surgery.  No. 
in.     Jaiiuary,  184:0.  J).  212.) 

Case  LXXXH. — Dr.  George  Bushe,  of  New  York,  wit- 
nessed in  a  new-born  infant  brought  into  the  dissecting  room, 
that  the  rectum  above  a  well  formed  anus,  was  intercepted 
by  two  membranous  partitions.  They  were  both  quite  thin 
and  friable  and  about  three  quarters  of  an  inch  apart,  the 
h)wer  one  being  about  half  an  inch  above  the  anus.  The 
r(!ctum  above  these  membranous  sejita,  was  loaded  Avitli  gas 
and  meconium.     (A  Treatise  on  the  Jfalfor  mat  ions,  Injuries 


THE    FOUUTII    SPECIES    OF    M AI.KOUMATKJN.  183 

and  Diseases  of  the  lieduni  and  Anus.     Chapt.  TIT.  p.  40 

New  York:  18;}7.) 

Case  LXXXIII. — M,  Voilleinier,  reports  tlie  case  of  an 
infjint  ])resentiii<^  a  iioriiuil  anus,  bnt  the  rectnni  was  divided 
by  nuMiibranons  partitions,  into  four  distinct  conipjirtnients, 
of  M'hicli  the  superior  one  only  contained  ineconinni  and  gas, 
the  otliers  enclosing  a  tliick  mucus.  {Gazette  des  Ilopitaux 
de  Paris.     J?m(?<?'l84().) 

Case  LXXXLV. — Dr.  Herman  Friedberg  mentions  a  case  of 
this  species  of  malformation,  in  the  pathological  portion  of 
his  able  essay  on  Artlfic/ial  Anus. 

The  case  was  that  of  a  new-born  female  child,  whose  anus 
was  well  formed,  but  the  anal  canal  was  closed  a  little  above 
the  sphincter.  The  attempt  made  to  open  it  by  puncture 
produced  no  evacuation  of  meconium,  and  the  child  died  six 
days  aft^r  birth. 

At  the  autopsy,  the  walls  of  the  intestine  were  found 
adhering  to  each  other  and  closely  united  in  two  different 
places.  Dr.  Friedberg  was  of  opinion  that  this  cohesion  was 
canned  by  inflammation  of  the  rectum  during  foetal  existence. 

Case  LXXXV. — The  following  interesting  case  of  imper- 
foration  of  the  rectum  above  a  well-formed  anus,  is  reported 
by  M.  Amussat. 

■^ ''On  the  22d  of  December,  1842,  M.  le  docteur  Schuster 
sent  me  a  new-born  male  infant  who  had  passed  no  meconium 
since  his  birth.  The  child  well-formed  and  developed  in  all 
other  respects,  w\as  born  on  the  20tli  at  seven  o'clock,  P.  M., 
and  as  the  anus  perfectly  well-foiuned  pi-esented  an  opening 
of  the  usual  size,  there  was  no  immediate  suspicion  of  an  im- 
perforate rectum.  But  after  administering  purgatives  for  two 
days  they  sought  to  account  for  the  condition  of  the  child,  who 
vomited  all  that  he  received  upon  his  stomach,  and  whose 
abdomen  was  becoming  sensibly  larger.  Upon  introducing 
the  finger  and  a  sound,  imperforation  was  discovered. 

"When  ^ve  saw  the  child,  liis  abdomen  was  swollen,  his  skin 
presented  the  violet  hue  common  in  cases  of  obstruction  of  the 
venous  circulation,  and  he  cried  incessantly. 

"  A  sound  introduced  by  the  anal  opening  penetrated  M'ith- 
out  difficulty  a  distance  of  about  seven  eighths  of  an  inch. 
At  this  Inuglit  it  encountered  an  obstruction  which  it  could 
not  overcome.  The  little  finger  was  likewise  arrested  at  the 
same  height,  and  there  was  no  perceptible  fluctuation  indicat- 


184  THE   FOUKITI   SPECIES    OF   MALFOEMATIOlSr. 

iiig  that  tlie  upper  })art  of  the  rectum,  distended  by  meconi- 
um, terminated  immediately  above  the  closure. 

"  By  percussion  of  the  regions  of  the  perin^eum  and  coccyx, 
verv  considerable  fluctuation  was  perceived  just  behind  tlie 
anus.  This  fluctuation,  particularly  evident  when  the  child 
cried  and  made  any  straining  effort,  or  when  pressure  was 
nuide  upon  the  abdomen,  was  clearly  recognized  by  all  the  as- 
sistants. Was  it  an  indication  that  the  upper  part  of  the  rec- 
tum, deviating  from  its  ncirmal  course,  terminated  near  the 
skin  of  that  region?  It  was  quite  probable,  but  hj  no  means 
certain.  Besides,  on  examinat-ion,  the  coccyx  was  found  not 
to  be  as  much  curved  as  is  customary  with  well-formed  child- 
ren, indicating  that  the  intestine  developing  itself  in  its  inferi- 
or portion,  had  pushed  back  the  coccyx  in  order  to  make 
room  for  itself.  At  all  events,  so  unusual  a  circumstance  as  a 
fluctuation  extremely  perceptible  behind  the  anus,  and  alto- 
gether unperceived  by  examining  the  anal  aperture  with  the 
linger,  was  sufficient  to  embarrass  the  operator,  and  render  him 
undecided  about  the  proper  course  to  take.  Should  he  incise 
the  closure,  making  use  of  the  anal  opening,  or  would  it  ])e 
better  to  form  an  artiticial  anus  between  the  normal  c»])ening 
and  the  coccyx,  at  the  precise  point  where  the  evident  fluctu- 
ation indicated  almost  surely  that  the  upper  end  of  the  rec- 
tum, imperforate,  had  reached  by  its  distension  within  a  very 
small  distance  of  the  skin  ? 

'•After  reflection,  I  decided  on  the  latter  operation.  The 
fluctuating  tumor  was  incised  with  a  bistoury,  plunged  deeply, 
upon  the  withdrawal  of  which  gas  and  meconium  were  voided. 
The  opening  having  been  enlarged,  a  sound  and  the  flnger 
were  introduced  into  the  artificial  anus.  A  great  quantity  of 
meconium  flowed.  Satisfied  with  the  haj^py  result  of  the  op- 
eration thus  far,  I  reflected  on  the  means  necessary  to  restore 
a  part,  if  not  all  its  functions  to  the  natural  anus.  M.  Vidal, 
of  Poitiers,  one  of  the  assistants,  proposed  enlarging  the  open- 
ing on  the  side  of  the  anus,  in  order  to  make  one  cavity  of  the 
two  which  existed.  A  grooved  sound  soon  perforated  the  thin 
memljranous  obstruction  which  separated  the  two  ends  of  the 
rectum.  It  was  incised  with  the  scissors  after  catching  it  with 
the  finger  and  brin^ino-  it  down.  The  intestinal  mucous  mem- 
Itrane  was  smooth  and  soft,  and  the  finger  was  covered  as  by 
a  hood  with  the  anterior  portion  of  the  partition.  The  child 
was  bathed  and  cleaned.  Emollient  injections  were  recom- 
mended for  the  wound,  and  sitz  Ijaths  were  advised.  The 
child  was  brought  to  us  daily,  and  his  condition  gradually 
improved. 

"  An  elastic  canula  was  introduced  from  time  to  time  dur- 


THE    FOURTH    8PKCIES    OF   MALFORMATION.  185 

ing  the  dny,  into  tliu  anal   upenino;,  to    dilate   it  and   j)r('vcnt 
contraction. 

"At  this  date,  February  IStli,  1843,  the  child  seeins  as  well 
as  tliough  it  had  never  endured  so  grave  an  <»[)eration. 

'■'•Ileflectunus. — The  diagnosis  has  been  ])eri'ectly  justified  1)V 
the  operation.  My  ideas  formed  at  the  time  of  the  oj)eration 
and  leading  me  to  this  diagnosis  were  as  follows:  When 
fluctuation  was  not  ])erce])tible  to  the  little  finger  introduced 
into  the  cul-de-sac  of  the  I'ectum,  (Hie  would  hardly  have  im- 
agined that  it  would  be  discovered  behind  and  lower  down  : 
it  would  naturally  be  supposed  that  the  other  end  of  the  in- 
testine was  higher  up ;  but  on  reflection  we  see  the  thing  is 
possible,  and  the  fact  proves  it.  It  is  very  probable  that  in 
all  analagous  cases  it  must  be  so,  but  in  a  variable  degree,  ac- 
cording to  the  distention  of  the  upper  end. 

"  The  operation  in  the  rear  of  the  cnl-de  sac  of  the  rectum, 
was  perfectly  successful.  After  incision  into  the  meconial 
pouch  the  gas  and  meconium  were  immediately  evacuated. 
I  enlarged  the  opening,  and  introduced  a  sound  and  the  little 
finger  without  any  difficulty.  I  subsequently  enlarged  the 
opening  yet  more  at  its  lower  part,  in  order  to  make  the  anus 
servicable,  and  finally  with  a  grooved  director,  I  penetrated 
the  thin  mucous  membrane  which  formed  the  obstruction.  I 
cut  it  entirely  through,  and  the  normal  anus  consequently 
now  communicated  with  the  artificial  opening  made  behind  it. 
W^ith  the  little  finger  I  recognized  the  mucous  membrane, 
as  well  as  a  part  of  the  separating  membrane  covering  the 
finger  like  a  hood  ;  finally,  I  removed  this  portion  of  the  ob- 
struction with  the  scissors,  and  then  the  finger  could  be  easily 
introduced  into  the  rectum  without  encountering  any  other 
obstacle. 

"  From  the  description  of  the  operation  it  is  easy  to  infer 
the  pathological  condition  of  the  intestine.  It  is  evident  that 
the  rectum  M'as  closed,  or  strangulated  about  one  inch  and  a 
quarter  from  the  anus  ;  in  this  state  the  other  end  of  the  intes- 
tine was  distended  and  extended  back,  having  displaced  the 
coccyx,  taking  its  position  between  the  inferior  extremity  of 
the  coccyx. 

"  We  must  perceive  that  the  same  disposition  of  parts  exist 
when  the  pathological  condition  is  the  same. 

"  It  would  be  higldy  interesting  to  examine  an  anatomical 
specimen  of  this  kind,  in  order  to  see  the  cause  of  imperfora- 
tion,  and  the  adhesion  of  the  cul-de-sac  in  front. 

"  Although  it  was  impossible  to  recognize  the  fluctuation  at 
the  bottom  of  the  cul-de-sac,  if  we  had  operated  there  with 
the  trocar  or  the  bistoury  in  the  ordinaiy  manner,  we  should 


186  THE  Fouirni  speciks  of  malfokmation. 

undoubtedly  have  completely  evacuated  the  meconiuui ;  but 
■\ve  know  the  difficulty  of  keeping  the  opening  sufficiently 
dilated.  The  cul-de-sac  of  the  upper  end  would  have  inter- 
posed a  serious  obstacle  to  the  flow  of  the  fgecal  matter. 

"  Previous  to  this  case  I  have  always  endeavored  to  bring 
down  the  upper  extremity  to  the  anus,  after  having  cut  on 
the  inferior  end  in  the  rear. 

"  It  is  evident  that  the  oj^eration  on  this  last  child  is  far  pre- 
ferable and  more  simple  in  execution.  It  is  like  a  grand  op- 
eration for  fistula  in  ano. 

"  The  diagnosis  being  the  same,  would  it  not  be  preferable 
to  cut  the  anus  behind,  in  order  not  to  ascend  too  high  by  the 
side  of  the  coccyx.  With  a  small  straight-bladed  bistoury, 
the  point  covered  with  a  small  wax  ball,  we  might  at  first  en- 
large the  anus  towards  the  rear,  in  order  to  explore  and  direct 
for  the  rest  of  the  operation." — {L* Examinaieur  Medical  d^ 
Paris.     Atinee  1843.     tome  III.    No.  17.   ]).  216.) 

Case  LXXXYI. — Dr.  Condie  reports  a  case  as  follows — 
"We  have  lately  seen  a  case  of  this  species  of  malformation,  in 
wliicli  the  obstruction,  consisting  of  a  transverse  membrane, 
existed  about  an  inch  and  a  half  within  the  anus,  the  lower 
]>ortion  of  the  rectum  being  in  all  respects  perfectly  formed. 
The  cl)ild  lived  four  days,  and  until  within  a  few  hours  pre- 
vious to  death,  presented  no  indication  of  the  existence  of  tlie 
obstruction,  excepting  the  absence  of  all  discharges  from  the 
bowels.  Shortly  before  death,  great  tumefaction  of  the  abdo- 
men from  the  development  of  gas  took  place,  with  evident 
])ain  upon  pressure  of  any  portion  of  the  abdomen.  No 
operation  was  permitted  by  the  parents. 

"  An  examination  of  the  body  revealed  the  nature  of  the 
obstruction — a  firm  membranous  partition  existing  about  one 
and  a  half  inches  above  the  termination  of  the  gut,  and 
forming  a  complete  obstacle  to  the  furtlier  passage  of  the 
contents  of  tlie  bowels.  The  small  intestines  were  perfectly 
empty,  greatly  contracted,  and  free  from  the  least  trace  of 
disease  ;  the  colon  was  enormously  distended  with  gas,  and 
tlirough  its  whole  extent,  injected  with  blood.  The  upper 
portion  of  the  rectum  was  likewise  greatly  distended,  and 
contained  nearly  eight  fluid  ounces  of  meconium,  and  thick 
ropy  mucus;  its  mucous  coat  presented  very  decided  marks 
of  inflammation."  [A  PmotiGol  Treatise' on  the  Diseases 
of  Childi'en.i?.  191.  Philadeljyhia  :  1814.) 

Case  LXXXYII. — The  f  )llowing  case  oi  imperforation,  or 


THE    FOURTH    SPECIES   OF   MALFORMATION.  187 

rntliei*  absence  of  the  rectum,  ahovc  a  normal  anus,  is 
reported  l).y  Pn^tiessor  James  Jones  of  New  Orleans. 

"The  iirst  case  in  my  )>ractice,"  says  Dr.  Jones,  '•  occurred 
in  February,  1846.  I  delivered  a  lady  of  a  fine  boy  on  the 
morning  of  tlie  13tli,  and  as  she  lived  two  and  a  half  miles 
fn>m  my  residence,  left  her  in  charge  of  a  very  experienced 
nurse,  who  now  practises  with  some  re])utati()n  as  a  midwife. 
Next  day  she  informed  me  that  the  child  had  as  yet  no  pas- 
sage from  the  bowels,  notwithstanding  the  exhibition  of  olive 
and  of  castor  oil,  and  also  of  two  enemata.  The  child  was 
very  restless  and  fretful,  vomited  and  had  a  very  tense  belly, 
I  took  the  syringe  which  had  a  long  ivory  nozzle,  and  using  it 
as  a  sound  fur  the  examination  of  the  anus  and  rectum,  found 
to  my  regret  that  it  would  only  penetrate  about  half  an  inch, 
and  that  the  anus  [rectum)  was  imperforate.  I  immediately 
made  an  incision  with  my  lancet  to  the  depth  of  half  an  inch 
more,  and  finding  by  the  introduction  of  a  cataract  needle  an 
inch  and  a  half,  that  neither  air  nor  liquid  of  an}'  kind  made 
its  appeai'ance,  I  called  Dr.  Stone  into  consultation,  who  dis- 
approved of  further  incisions,  and  dilated  that  already  made 
to  the  depth  of  an  inch  and  a  half  unsuccessfully.  The  abdo- 
men became  more  tense,  the  child  gave  evidences  of  great 
suffering  and  died  on  the  next  day." 

"  The  post-mortem  was  made  on  the  17th,  by  my  friend 
Dr.  Lemonnier.  The  intestines  were  all  greatly  distended, 
and  the  surface  of  the  peritoneum  covered  with  coagulable 
lymph.  The  lower  portion  of  the  colon,  which  was  the  ]iart 
most  enlai'ged,  terminated  at  the  promontory  of  the  sacrum, 
in  a  cul-de-sac,  tilled  with  meconium.  There  was  a  complete 
absence  of  the  rectum,  and  the  end  of  the  colon  had  two 
little  punctures  made  by  the  needle,  from  which,  apparently, 
nothing  had  escaped.  If  {\\Qy  had  been  larger,  the  contents 
would  have  been  emptied  into  the  cavity  of  the  pelvis." 
{New  0 deans  Medical  and  Surgical  Journal.  Vol.  XY.  ^y. 
98.  1858.) 

Case  LXXXYIII. — M.  Baudelocque  mentions  the  case  of 
a  child  two  days  old,  presenting  a  natural  anus,  but  having 
voided  no  meconium.  On  passing  the  little  finger  of  his  left 
hand  into  the  rectum,  he  found  that  organ  terminated  in  a 
cul-de-sac,  about  one  inch  above  the  anus.  He  made  an  inci- 
sion through  the  occluding  membrane  with  a  sharp-pointed 
probe  through  a  canula,  and  the  meconium  immediately  found 
a  passage,  and  the  child  was  relieved. 

Baudelocque  subsequently  performed  the  same  operation  in 
apparently  a  similar  case,  but  it  completely  failed.     He  then 


188  THE    FOURTH    SPECIES    OF   MALFORMATION. 

successfully  perfonned  colotoiny  after  the  method  of  Callisen, 
modified  by  Amussat.  [Memolre  de  VAcadeinie  Roy  ale  des 
Sciences.  Paris :  Aout  et  Octobre.  1844.  Also^  London 
Lancet.      Vol.  I.     Fehtniary,  1845.) 

Case  LXXXIX. — John  Pikcop,  Esq.,  a  London  surg-eon, 
reports  the  folh)\ving  case  of  imperforate  rectum  above  a  nat- 
ural formed  anus. 

"  On  the  13th  of  Jul}',  1849,  I  attended  Mrs.  M- ,  in 

labor  of  her  first  child,  a  female.  During  my  visit,  the  fol- 
lowing day,  I  was  informed  that  the  child's  bowels  had  not 
been  moved;  but,  hoping  they  might  be  during  the  day,  I 
took  little  notice  of  the  remark. 

"  Julv  loth. — -The  bowels  still  unmoved,  thoucrh  castor  oil 
had  been  given.  The  child  would  not  take  the  breast,  and 
vomited  an}-  fluid  almost  as  soon  as  taken.  Bowels  much  dis- 
tended. Retching,  hiccough,  and  other  symptoms  of  severe 
enteritis.  Ordered  a  calomel  powder  immediatel}^,  and  a  tea- 
spoonful,  every  three  hours,  of  a  mixture,  containing  a  saline 
laxative,  with  tinctures  of  cardamoms  and  henbane. 

"16tli. — Vomiting  abated.  Belly  still  as  usual,  without 
any  evacuation.  I  proceeded  to  inject  a  little  warm  water 
per  anum,  but  was  surprised  to  find  it  instantly  returned,  un- 
altered. This  induced  me  to  introduce  my  fino-er,  as  I  ima- 
gined  there  might  exist  some  imperfection  in  the  passage.  On 
doing  so,  I  found,  that  when  my  finger  had  passed  about  an 
inch  and  a  half,  the  bowel  was  closed,  precisely  like  the  end 
of  the  fino-er  of  a  glove.  I  could  not  detect  any  distended 
portion  of  bowel  to  correspond.  This  condition  of  parts  fully 
disclosed  the  nature  of  the  case.  I  explained  to  the  mother 
the  immediate  necessity  of  an  operation,  to  afford  the  child 
any  chance  of  life,  to  which  she  consented. 

"17th. — In  the  presence,  and  with  the  advice,  of  Mr.  Grime, 
surgeon,  and  Dr.  Irvine,  I  introduced  a  sharp-pointed  bis- 
toury, against  my  finger,  to  the  seat  of  obstruction,  and 
pushed  it  on  about  an  inch.  On  withdrawing,  nothing 
escaped  but  a  little  venous  blood.  I  then  passed  through  the 
opening  a  small  bougie,  on  M'hich  being  removed,  there  fol- 
lowed a  copious  discharge  of  meconium  and  other  matter. 
From  this  time  the  child  became  easier,  and  on  the  following 
day  began  to  take  the  breast.  The  mixture  was  continued 
for  a  few  davs,  and  also  the  introduction  of  the  bougie.  The 
bowels  are  regularly  moved,  and  the  child  is  in  perfect 
health. 

"The  removed  extremities  of  the  rectum  appeared  to  be 
connected  bv  a  short  band  of  fibrous  membrane.     I  have  be- 


THE    FOUKTII    SPKCIKS   OF   MALFORMATION.  189 

fore  Hi'c'ii  cases  ul'  iiiu)L'rli)riite  iuius,  I)iif,  not  of  iiii[)crvi()us  roc- 
timi."     {London  Lancet^   Vol.  7.,  Maij:   1S50.  2>.  510.) 

Cask  XC. — Von  Sclileiss,  of  Muiiicli,  iv])()rt.s  the  (^iise  of  ii 
male  infant  in  whom  the  rectum  was  imperforate  about  one 
inch  above  a  well-formed  anus.  JJeyoiid  the  point  of  im])er- 
foration,  the  rectum  was  absent,  and  the  colon  terminated  in 
a  cul-dc-sac.  Schleiss,  by  a  very  lucky  phuii^o  with  a  trocar, 
readied  and  penetrated  the  blind  end  of  the  inferit)r  extremity 
of  the  colon,  without  wounding  the  Ijladder  or  any  of  the  pel- 
vic viscera.  Success,  under  numerous  difficulties,  finally 
attended  the  operation. 

On  the  11th  of  October,  1850,  Mrs.  J.  St ,  a  healthy 

wonuin  of  Munich,  aged  twenty-two  years,  was  delivered  of 
her  second  child,  a  boy,  like  her  first  still  living,  healthy  and 
well-formed  ;  no  appearance  extermdly  whatever  of  any  de- 
formit}'.  The  child  seemed  quiet,  had  passed  urine,  but  had 
taken  no  nourishment,  neither  had  it  evacuated  any  meconiuui 
for  twenty-four  hours.  The  midwife  in  charge  of  the  case  ad- 
ministered an  enema,  but  it  iinn)ediately  returned  without 
producing  any  effect.  Late  in  the  evening  of  tlie  12th  of  Oc- 
tober, Von  S'chleiss  was  called,  and  the  midwife  made  him 
acquainted  with  all  the  circumstances  of  the  case,  so  far  as 
she  knew.  He  observed  that  the  child  made  strange  move- 
ments with  its  mouth  and  tongue,  being  between  those  of 
licking  and  those  which  precede  vomiting.  Upon  examina- 
tion of  the  perinseal  region,  he  found  the  aims  normal,  but  on 
introducing  his  little  finger  he  found  the  canal  completely  ob 
structed  about  an  inch  above  the  anal  orifice.  The  cavity  of 
this  portion  of  the  rectum  was  empty,  and  no  trace  of  mecn- 
nium  could  be  perceived,  he  therefore  became  assured  that  its 
continuity  was  interrupted,  and  that  it  ended  in  a  blind  sac; 
and  that  there  was  actually  before  him  a  case  o^  atresia  recti. 
In  consequence  of  the  lateness  of  the  hour  in  which  he  made 
this  discovery,  he  postponed  further  proceedings  till  next 
morning,  remindful  of  the  advice  of  Diefi'enbach,  to  defer  op- 
eratino;  in  such  cases  till  the  second  day.  The  child  remained 
quiet  during  the  night,  except  the  movements  of  its  mouth  and 
tongue,  which  were  increased  in  violence,  without,  however, 
resulting  in  real  vomiting ;  but  then  it  had  taken  no  w\ater 
nor  any  nourishment,  and  had  passed  no  meconium.  On  the 
morning  of  the  13th  of  October,  he  made  a  more  thorough 
exploration  of  the  parts,  by  introducing  a  small  silver  cathe- 
ter into  the  bladder,  and  his  little  linger  as  well  as  a  small 
probe  into  the  rectum.  This  examination  resulted  in  the  con- 
viction, that  between  the  point  of  obstruction  in  the  rectum. 


190  THE   FOURTH    SPECIES    OF   MALFORMATION. 

and  the  inferior  extremity  of  the  colon,  tlie  former  was  defi- 
cient,  and  that  no  communication  whatever  existed  between 
the  two ;  that  the  bladder  which,  in  this  case,  was  wide  and 
deep,  had  advanced  as  far  as  to  the  sacrum,  to  the  anterior 
surface  of  which  it  was  adherent,  was  lying  between  these 
two  points — that  is,  between  the  blind  end  of  the  rectum,  and 
the  blind  end  of  the  inferior  extremity  of  the  colon. 

Von  Schleiss  was  of  opinion  that  this  was  a  case  sui  generis^ 
and  that  no  method  of  operating  heretofore  recommended 
was  at  all  applicable  to  it.  He  however  determined  on  this 
occasion  to  use  the  trocar  usually  employed  for  paracentesis 
abdominis,  the  child  being  placed  on  its  right  side  with  its 
thighs  drawn  up  and  nates  separated.  Presuming  that  the 
blind  sac  of  the  inferior  extremity  of  the  colon  would  be 
situated  more  to  the  left,  as  in  its  normal  place,  Schleiss 
introduced  the  trocar  through  the  anal  orifice  into  the  rectum, 
and  pressed  it  to  the  left  of  the  rectum  by  the  side  of  the 
false  vertebra  of  the  sacrum,  and  between  the  latter  and  the 
posterior  wall  of  the  bladder  into  the  cellular  tissue  which 
united  them  ;  and  then  pushing  the  stilette  strongly  in  the 
direction  indicated,  he  experienced  the  sensation  of  having 
traversed  five  or  six  lines  of  cellular  tissue,  and  then  having 
penetrated  a  cavity.  On  witiidrawing  the  stilette  he  found 
the  point  soiled  with  meconium  ;  and  upon  pushing  the 
canula  still  further  upwards  through  the  wound  which  had 
been  made,  into  the  cavity,  meconium  immediately  flowed 
through  it.  The  child  at  once  improved  in  every  respect,  and 
for  the  first  time  took  the  breast.  The  silver  canula  of  the 
trocar  was  allowed  to  remain  in  place  for  nine  days,  when  it 
was  replaced  by  elastic  tubes  of  gradually  increased  sizes  ; 
and  at  last  after  four  weeks  these  were  laid  aside  altogether. 
The  faecal  matter  now  passed  easily  through  the  newly  made 
canal. 

AVhen  the  child  began  to  pass  more  solid  faecal  matter, 
occasional  difficulties  occurred,  which  increased  until  it  was  a 
year  old.  It  seemed  compelled  to  make,  at  different  times, 
two  distinct  efforts  to  accomplish  the  evacuation  of  its  bowels. 
At  the  first  efibrt  its  uneasiness  and  cries  only  ceased  after 
tlie  faecal  matter  had  passed  the  newly  formed  passage  from 
the  colon,  and  had  become  lodged  in  the  cavity  of  the  rec- 
tum. At  this  effort  no  fcBcal  matter  whatever  would  pass  by 
the  anus.  At  a  subsequent  period,  however,  when  to  all 
aj)pearance  no  marked  efforts  were  being  made  to  defecate, 
manifestly  limited  to  the  rectal  region,  they  were  nevertheless 
followed  by  evacuation.  The  child  often  remained  several 
days  without  stooling,  and  made   useless  and  painful  efforts. 


THE   FOURTH    SPECIES    OF    MALFORMA.TI()N.  191 

On  examining  tlie  rectnin  with  the  tinger,  tlic  rectal  cavity 
was  found  to  bo  lilled  with  scybala;  it  was  sonieliiiies  neces- 
sary to  exti'act  them  with  the  linger.  After  regular  inJectioUH 
of  cohl  water  had  been  used  for  some  time,  evacuation  became 
easier  ;  however,  dithculty  of  evacuation  occurred  from  time 
to  time.  Twenty-live  months  after  the  operation,  tiie  child 
was  healthy  ;  the  artilicial  caual  between  the  colon  and  the 
rectum,  passing  behind  the  bladder,  was  three  or  three  and  a 
half  lines  in  diameter.  Yon  Schleiss  hoped  tliat  it  would  be- 
come yet  larger  as  the  child  grew  older,  lie  encountered 
much  trouble  and  dithculty  in  the  treatment  of  this  case,  in 
consequence  of  the  occurrence,  lirst  of  und)ilical,  then  of 
inguinal  hernia  on  each  side,  douhtless  the  result  of  the 
straining  efforts  of  the  child  to  evacuate  its  bowels,  together 
with  its  constant  cries.  {ZeltscJirift  fiir  Rat'ionelle  Medicin. 
Ncue  Folije.    Band.  III.  S.Zm.     lleidelberg  :  1^^)^.) 

Case  XCI. — ^The  following  case  was  communicated  to  the 
editor  of  the  ^''Boston  Medical  and  Surgical  Jouraal^''  by  Dr. 
A.  Bryant  Clarke,  in  a  letter  dated  llolyoke,  Mass.,  February 
10th,  i852. 

"I  attended  a  lady,  the  mother  of  several  healthy  children, 
in  her  coniinement  on  the  5tli  of  April  last,  who  was  delivered 
of  a  tine,  plump-looking  boy,  and  to  all  apj^earance  perfectly 
developed.  On  calling  the  next  day,  the  mother  and  child 
appeared  to  be  doing  well.  To  my  inquiries,  however,  the 
nurse  stated  that  nothing  had  passed  its  bowels.  A  slight 
laxative  was  ordered,  with  directions  to  use  injections  by 
evening  if  nothing  passed.  The  second  day,  nothing  having 
passed,  and  the  nurse  not  being  able  to  inject  anything,  I  was 
led  to  examine  the  rectum.  I  could  pass  my  little  finger  into 
the  anus  without  difficulty,  but  after  passing  about  three- 
f  )urths  of'  an  inch  it  met  with  firm  resistance,  appearing  to 
terminate  in  a  cul-de-sac.  The  nature  of  the  case  was  now 
made  known  to  the  mother,  and  the  only  means  of  relief,  an 
operation,  was  proposed ;  but  as  her  husband  was  absent,  she 
declined  having  it  done  until  his  return.  Circumstances  pre- 
vented this  until  the  evening  of  the  seventh  day.  He  at  lirst 
declined  an  operation,  but  seeing  how  w^ell  the  child  continued 
to  be,  and  after  consultino- a  neio-hborino;  surgeon,  he  consented 
to  have  an  operation  performed  on  the  morning  ot  the  ninth 
day.  I  made  use  of  a  trocar  and  canula.  After  passing  the 
trocar  through  the  canula,  I  withdrew  it,  but  no  meconium 
followed.  Raving  pushed  up  the  canuUx  into  the  opening 
made  by  the  trocar,  I  again  inserted  the  latter  and  withdrew 
it,  when  the  meconium  followed  in  abundance.     The  child 


192  THE    FOUKTH   SPECIES    OF   MALFORMATION.  ' 

made  no  cries,  and  seemed  to  be  relieved  by  the  operation. 
But  very  little  blood  was  lost.  Yet  the  child  died  in  about, 
twenty-tbur  hours. 

"The  parents  being  very  intelligent  and  well-informed, 
kindly  consented  to  an  examination,  which  was  had  the  next 
day.  On  laying  open  the  cavity  of  the  abdomen,  the  colon 
was  found  adlierent  throughout  its  course  uj^on  the  left  side 
to  the  internal  walls  of  the  cavity  of  the  abdomen.  The 
abnormal  state  of  the  rectum  was  now  seen  to  consist  of  a 
fleshy-looking  mass,  interspersed  with  fat  and  cellular  sub- 
stance, which  made  it  resemble  the  muscular  tissue  of  other 
parts,  and  to  close  up  the  rectum  for  the  space  of  about  an 
inch  and  a  half.  Upon  examination  it  was  found  the  trocar 
had  gone  directly  through  the  centre  of  the  mass,  and  was 
perfectly  successful,  so  far  as  the  operation  was  concerned. 
It  was  observed  that  there  was  a  fetid  smell  to  the  urine  the 
day  before,  and  there  is  no  doubt  that  the  means  of  relief 
were  too  late."  {Boston  JSLedical  and  Surgical  Journal.  Yol. 
XL  VL  p.  100.     Boston :  1853.) 

Case  XCIL — Groeschler,  of  Prague,  reports  the  following 
interesting  case  of  imperforation  of  the  rectum,  the  anus,  in 
the  meantime  being  normal.  In  this  instance  the  rectum 
was  obstructed  at  two  points,  first,  by  a  membranous  septum, 
at  half  an  inch  above  the  verge  of  the  anus  ;  then  again  at 
two  inches.  Beyond  this  second  obstruction  the  rectum  was 
entirely  wanting,  the  colon  terminating  in  a  cul-de-sac. 

Mrs.  A.  S ,  aged  thirty-nine  years,  the  wife  of  a  shoe- 
maker, was  delivered  on  the  10th  of  July,  1854,  of  a  vigorous 
and  to  all  appearance  a  healthy  and  iine  conditioned  boy. 
The  child  urinated  regularly,  but  could  not  evacuate  its  bow- 
els. On  tlie  next  day,  after  giving  it  some  mai'sli-mallow  tea, 
vomiting  ensued,  and  the  midwife  in  attempting' to  adminis- 
ter an  enema,  met  an  obstruction  within  the  anus,  which 
induced  her  to  call  in  the  aid  of  Goeschler. 

On  the  30th  of  July,  at  eleven  o'clock,  A.  M.,  Goeschler 
arrived,  and  upon  percussing  the  child's  abdomen,  he  discov- 
ered a  clear  full  tympanitic  sound  ;  its  respiration  was  hur- 
ried ;  and  its  hands  and  feet  were  of  a  violet  hue.  The  local 
examination  of  the  perinanim,  which  he  made,  resulted  in 
finding  a  well  formed  anus,  surrounded  ])y  a  sphincter  capa- 
ble of  contraction  ;  but  an  ivory  sound  which  he  attempted 
to  introduce,  entered  onh'  about  half  an  inch,  being  obstructed 
by  tlie  closure  of  the  intestine  at  that  p(^int.  This  obstacle 
ha\'ing  been  incised  by  means  of  a  pointed  bistoury,  he  suc- 
ceeded in  introducing  the  sound  about  two  inches  ;    but  at 


TIIF,    FOUKTir    SPECIES    OF   MAI.FOKMATIOX.  193 

this  point  there  was  fouii<l  a  second  ocehision  as  complete  as 
the  first,  and  allowing  neither  evacuation  of  the  meconium, 
nor  li(|ui(l  injection,  (loesc^lih'r  pert'oi-utcd  this  second  obsta- 
cle 1)}'  means  of  a  trocar,  and  inunediately  two  lai'ge  spoon- 
fuls of  meconium  ])assed  out.  The  swellino;  of  the  abdomen 
at  once  diminished  ;  the  sound  and  the  l)ipe  of  the  syringe 
were  easily  introduced,  and  an  eiu'iua  of  cold  water  was 
administered.  A  large  elastic  catheter  was  now  placed  in  the 
newly  made  canal.  At  the  end  of  two  hours  the  infant  grew 
pale,  the  tension  of  the  abdomen  returned,  the  extremities 
became  l)luo,  and  respiration  was  hurried  ;  the  evacuation  of 
meconium  ceased  by  degrees,  and  death  occurred  about  six 
o'clock  P.  M. 

The  autopsy  was  made  by  Professor  Engel,  and  gave  the 
following  results— The  anus  was  well  formed,  but  from  a  short 
distance  above  it  to  the  promontory  of  the  sacrum,  the  rectum 
was  com})letely  wanting :  the  bladder  was  normal.  The 
blind  end  of  the  colon  was  about  the  hight  of  the  promontory 
and  attached  to  the  anterior  surface  of  the  sacrum  by  a  con- 
tinuation of  the  peritonaeum.  The  sound  introduced  into  the 
anus,  passed  into  the  artificial  canal,  and  thence  into  the 
opening  made  wdtli  the  trocar  in  the  closed  extermity  of  the 
colon.  The  canal  thus  formed  passed  along  the  line  usually 
occupied  by  the  rectum,  in  this  instance  filled  up  with  a  firm 
cellular  tissue.  The  abdominal  cavity  was  filled  with  licpiid 
meconium  ;  but  there  was  no  appearance  of  peritonitis,  nor 
was  there  any  trace  of  internal  hemorrhage."  ( Yiertel- 
jalirseht'ift  far  die  praktlsdie  Ilellkunde^  XII.  Jahrgang^ 
1855.  ///.  Band.  &\  IS!.  Fracj.) 

Case  XCIII. — Mr.  Bird,  translator  of  M.  Bouchut's  treatise 
on  the  diseases  of  children,  reports  a  case  as  follows : — ■ 

''  Through  the  kindness  of  my  friend  Mr.  Tapson,  I  have 
had  the  opportunity  of  witnessing  the  follovring  case ;  a 
female  child  was  born  nearly  dead,  with  feeble  respiration, 
blue  surface,  and  deformity  of  the  left  hand.  On  the  second 
day,  no  meconium  having  jjassed,  an  examination  was  made  ; 
the  anus  was  well  formed,  but  on  introducing  the  finger  an 
obstruction  was  discovered  about  half  an  inch  from  the  anus  ; 
it  gave  the  sensation  of  a  membrane,  which,  on  the  feeble 
effort  of  the  child  became  more  tense  ;  the  child  continuing 
in  a  state  of  cyanosis,  with  feeble  respiration,  any  operative 
proceeding  was  deemed  useless  and  cruel ;  it  died  on  the  fifth 
day,  having  taken  only  a  few  teaspoonfuls  of  nourishment ; 
there  was  no  vomiting  with  the  exception  of  a  single  effort, 

18 


194  THE   FOUKTH   SPECIES   OF   MALFOKMATIOISr. 

on  the  second  day,  when  a  little  fluid  tinged  with  bile 
escaped ;  the  abdomen  became  much  distended  before  death. 
"  Autopsy. — Lungs  free  from  congestion,  collapsed,  but 
restored  by  insufllation;  it  was  evident,  however,  that  air  had 
never  entered  some  portions,  which  required  strong  efforts  of 
insufllation  to  distend  them.  Both  auricles,  espcially  the 
right,  were  distended  with  clots  ;  the  foramen  ovale  was  only 
two-thirds  closed  by  a  thin  membrane,  the  free  edge  being 
directed  anteriorly  ;  the  ductus  arteriosus  Avas  widely  open. 
The  peritoneal  cavity  contained  much  gas  and  faecal  matters, 
but  there  was  no  trace  of  any  inflammatory  products.  About 
three  inches  from  the  appendix  vermiformis,  a  long  rent  in 
the  peritonseal  covering  of  the  colon  was  observed,  showing 
the  mucous  membrane  beneath ;  this  was  softened  and  thin- 
ned and  presented  a  circular  opening  less  than  half  an 
inch  in  diameter,  the  edges  of  which  were  irregular 
from  small  shreds  of  mucous  membrane  ;  the  vessels  were 
much  congested  in  tlie  neighborhood  of  the  rent,  but  no  signs 
of  inflammation  were  observed,  the  rent  being  apparently  the 
result  of  mechanical  distention.  The  rectum  terminated  in  a 
perfect  cul-de-sac,  the  distended  ha3morrhoidal  vessels  ramify- 
ing over  the  extremity,  all  the  coats  of  which  were  jDcrfect, 
and  not  the  slightest  trace  of  any  opening  was  observed ;  the 
vessels  of  the  mucous  membrane  were  considerably  injected  ; 
the  large  intestines  contained  no  meconium  but  a  large  quan- 
tity of  Arm  bright  colored  faeces."  {Practical  Treatise  on  the 
Diseases  of  Children.  By  M.  Boucliut.  Bird's  English  ver- 
sion. Booh  X.  Chap.  I.  p.  615.  London,  1855.) 

Case  XCIV. — Mr.  Ashton  reports  a  case  of  this  species  of 
malformation. 

"  I  have,"  says  he,  "  in  my  possession  a  preparation  given 
me  by  my  friend  Dr.  Qnain,  namely,  a  case  of  malformation 
of  the  rectum,  in  which  tlie  intestine  terminated  in  a  closed 
sac.  The  prepai-ation  was  presented  to  the  Pathological 
Society,  and  the  particuhirs  of  tlie  case  are  published  in  the 
Society's  Transactions.  ( Vol  1.  p.  280.)  The  anus  was 
perfect,  throngh  which  an  incision  was  made  by  the  surgeon 
in  attendance;  but  he  was  unsuccessfnl  in  opening  tlie 
bowel,  and  the  child  died  on  the  ninth  day."  {A  Treatise  on 
the  Diseases.,  Lijuries  and  Mcdformations  of  the  Rectum  and 
Anus.  By  T.  J.  Ashton,  M.  D.  Chap.  XIX.  p.  333. 
London :  1854.) 

Case  XCY. — S.  Parkman,  M.  D.,  reported  the  following 
case  to  the  Boston  Society  for  Iledical  Lnprovenient,  on  the 
13th  of  February,  1854. 


TUE   FOURTH    SPECIES    OF   MALFORMATION.  195 

"  The  patient  was  fifty-two  lioiirs  old  ;  anus  ])orfcctly 
formed;  obstruction  of  rectuni  nearly  two  inches  within  the 
anus.  Dr.  Parkuuin  waited  eighteen  hours,  until  the  septum 
became  distended  by  collected  meconium,  and  then  punctured 
the  ])ouch  with  a  trocar  ;  injecting  afterwards,  and  washing 
out  the  bowel.  This  process  was  repeated,  the  opening  not 
remaining  free,  a  director  was  passed  into  the  anus  and 
through  the  opening  made  by  the  trocar,  and  the  sphincter 
ani  and  the  septum  were  divided,  from  before  backwards,  l>y 
a  free  incision  ;  the  linger  could  then  be  passed,  and  went 
into  a  large  cavity.  After  the  operation  the  child  took  the 
breast  readily,  and  is  now  doing  well,  three  months  after  the 
operation.  l)r.  Parkman  directed  an  attendant  to  pass  a  well- 
oiled  finger  wnthin  the  opened  intestine  daily.  [Records  of 
the  Boston  Society  for  Medical  Iraprovement.  Vol.  W.  p. 
55.     Boston  :  185(>.) 

Case  XCVI. — S.  Cabot,  M.  D.,  of  Boston,  Mass.,  reported 
the  following  case  of  imperforatioii  of  the  rectum,  to   the 
"  Boston  Society  for  Medical  Improvement^''  on  tlie  28tli  ol 
September,  1857. 

Dr.  Cabot  saw  the  patient  on  the  fourth  day  after  birth  in 
the  evening,  at  which  time  it  was  reported  that  no  discharge 
had  taken  place  from  the  bowels.  Castor  oil  had  been  given, 
but  was  rejected.  An  injection  had  also  been  ordered.  The 
abdomen  was  now  found  distended.  On  examination  per 
rectum,  the  finger  passed  in  about  one  inch.  When  the  child 
strained,  the  intestine  could  be  felt  pushing  downward, 
the  central  portion  of  the  part  thus  pushed  down  feeling 
considerably  thicker  than  membrane.  A  trocar  was  thrust 
in,  and  a  large  quantity  of  fseces  and  meconium  discharged. 

On  the  following  morning,  two  probes  were  passed  in 
through  the  opening,  into  the  intestine,  as  was  supposed,  the 
largest  being  left  in,  and  a  piece  of  gum  elastic  catheter 
pushed  down  upon  it.  In  the  evening  it  was  reported  that 
nothing  had  passed  through  the  canula.  The  child  had  also 
vomited  foeculent  matter.  The  opening  was  now  eidarged 
by  the  knife  and  the  intestine  punctured  ;  this  being  followed 
by  the  discharge  of  a  small  quantity  of  gas  and  meconium. 
Death  took  place  on  the  following  day. 

It  was  found  on  examination,  that  the  internal  and  external 
cul-de-sac  approached  to  within  about  a  half  an  inch  of  each 
other,  and  that  the  probe  and  catheter,  instead  of  passing 
through  the  original  opening  into  the  intestine  had  made  a 
false  passage  in  the  cellular  substance  by  the  side  of  the  gut. 


lOG  THK    FOURTH    SPFXIIiS    OF   MALFORMATION. 

[Bonton  Medical  and  Surgical  Journai.      Yul.  L  YII. p.  238. 
Boston :  1857.) 

Case  XCVII. — The  following  case  is  reported  by  Dr.  G. 
S.  Jones.  It  was  read  before  the  Suffolk  District  Medical 
Society,  of  Mass.,  on  the  31st  of  October,  1857. 

"Tlie  subject  of  this  case  was  a  line,  phinip,  male  child, 
apparently  otherwise  in  a  liealthy  condition. 

••'  The  day  after  its  birth,  the  nnrse  directed  my  attention 
to  the  fact  that  it  had  had  no  discharge  from  its  bowels, 
although  efforts  had  evidently  been  made  to  effect  that  object. 
I  ordered  castor  oil  to  be  given,  and  if  it  failed  in  producing 
an  evacuation  from  the  bowels,  then  injections  of  warm  water, 
until  tlie  object  desired  was  obtained.  At  my  next  visit,  I 
was  informed  that  neither  the  oil  nor  injections  had  acconi- 
plislied  the  purpose  for  which  they  were  intended,  and  that 
the  little  patient  continued  to  have  a  "  bearing  down,"  which 
seemed  to  be  accompanied  with  much  suffering.  A  paroxysm 
of  this  effort  to  unload  the  bowels  coming  on  Mdiile  I  was 
present,  induced  me  to  make  a  more  thorough  examination 
of  his  condition,  than  I  had  done  at  my  previous  visit.  The 
abdomen  was  found  quite  tense  and  tympanitic  ;  as  he  passed 
urine  immediately  after  his  birth,  there  was  no  anxiety  or 
uncertainty  respecting  the  functions  of  the  bladder.  The 
anal  opening  was  normal,  and  freely  admitted  my  oiled 
linger,  but  in  attempting  to  pass  it  up  into  the  bowel,!  found 
that  it  could  not  penetrate  further  than  to  the  second  joint 
(about  one  and  a  half  inches,)  in  consequence  of  some  obstruc- 
tion. While  the  linger  was  in  the  passage,  tlie  little  fellow 
would  strain  and  bear  down  violently,  and  I  could  distinctly 
feel  the  blind  or  pouched  extremity  of  the  bowel  distended 
with  meconium.  The  case  was  evidently  a  clear  one,  and 
after  rej)resenting  its  condition  to  the  parents,  they  were 
exceedingly  anxious  to  have  me  operate  upon  the  child,  if 
there  was  the  least  chance  of  saving  its  life. 

"Having  decided  to  operate,  I  had  the  child  placed  upon  its 
back  in  the  lap  of  its  nurse,  with  its  legs  flexed  upon  tlie 
abdomen,  I  then  passed  a  very  small  bi-valve  speculum, 
through  the  anal  opening  up  to  the  point  of  obstruction,  when 
I  dilated  the  passage  to  "its  fullest  extent,  and  by  the  aid  of 
light,  I  was  now  able  to  see,  what  I  had  only  previously  felr, 
the  termination  of  the  impertbrate  bowel.  The  child  now 
straining  quite  hard,  forced  the  gut  down  very  tensely  ;  I 
then,  with  a  spear-pointed  stilette,  made  an  opening  into  it, 
and   copious  discharges  of  gas  and    meconium  followed   the 


TIIK   FOURTH    SPECIES    OF   MALFORMATION.  197 

withdrawal  of  the  iiistrmiicut.  The  ojxMiiiii;-  was  riirthcr 
C'nlari>:e(l  by  ;i  crucial  incision  across  the  end  of  the  pouch, 
and  i)y  the  use  of  gum-elastic  bougies ;  commencing  with 
one,  one  fourth  of  an  inch,  and  at  the  terminatifni  of  six 
weeks,  leaving  off  with  one,  half  an  inch  in  diameter.  It  is 
now  nearly  two  and  a  half  years  since  the  operation,  and  the 
child  appears  well  and  hearty,  and  suffers  no  inconvenience 
from  the  malformation  or  operation.  No  dr)ul)t  the  successful 
result  of  this  operation  was  in  part  due  to  the  speculum,  by 
the  aid  of  which  a  view  of  the  parts  could  be  fully  obtained, 
and  a  wrong  direction  could  hardly  be  given  the  instrument, 
in  perfin'ating  the  bowel  ;  and  also  to  the  persevering  use  of 
the  bougies  several  times  during  the  day  and  niglit,  for  a 
period  of  six  or  seven  Aveeks,  in  dilating  the  ojiening." 
{Boston.  Medical  and  Sargioal  Jonrnal.  Vol.  LVI/.j?.  293. 
Boston  :  185T.) 

Cases  XCVIII. — XCIX. — ^The  two  following  cases  of  im- 
perfo ration  of  the  rectum,  accompanied  by  a  normal  anus,  were 
reported  to  the  ''  Suffolk  District  Iledical  Society,''''  by  Doctor 
Ayer. 

First  Case. — The  first  case  was  a  male  child.  The  anus 
was  perfectly  formed.  On  introducing  the  linger  a  few  hours 
after  birth,  its  passage  was  obstructed  a  short  distance  from  the 
anus,  but  the  upp)er  portion  of  the  intestine  could  not  be  felt 
piressing  down  upon  the  finger  as  usuall}'  happens  in  these  cases. 
The  child  was  left  for  two  or  three  days,  when  Dr.  H.  J.  Bige- 
low  was  called  in  consultation.  At  this  time  a  distended  pouch 
could  be  felt  by  the  finger  pressed  into  the  rectum.  There 
was  also  feecal  discharge  through  the  urethra.  It  was  decided 
not  to  do  any  operation,  and  the  child  died,  in  eight  days  from 
its  birth. — {Boston  Medical  and  Surgical  Journal.  Vol. 
L  VII.  2>-  510.     Boston  :  1S58.) 

Second  Case. — The  second  case  reported  by  Dr.  Ayer,  oc- 
curred in  a  female  child,  and  what  was  most  remarkable,  of 
the  same  mother.  In  this  case  as  in  the  first,  the  anus  was  nor- 
mal and  there  was  a  passage  of  meconium  through  the  ure- 
thra. Dr.  II.  J.  Bigelow  was  also  called  in  consultation  in  this 
case.  The  child  was  not  operated  upon  and  died  in  a  few 
days. 

Dr.  Ilodgcs  made  the  autopsy  of  this  case.  On  opening 
the  abdomen,  which  was  greatly  distended,  the  rectum  pre- 
sented itself  and  seemed  to  fill  the  whole  cavity.  The  pelvis 
and  contents,  with  the  external  organs,  were  removed  toge- 
ther.    The  rectum  terminated  in  a  round  cid-de-sac,  and  was 


198  THE   FOURTH    SPECIES   OF   MALFOEMATION. 

•iilated  by  gas  and  meconium  in  a  fusiform  shape  for  six 
inches  or  more  above  its  termination,  being  largest  just  above 
the  brim  of  the  pelvis,  wliere  its  diameter  was  an  inch  and  a 
half  at  least.  The  anus  jjenetrated  about  half  an  inch,  and 
the  septum  between  it  and  the  rectum  was  three -sixteenths  of 
an  inch  in  thickness,  consisting  of  loose  celluar  tissue.  There 
was  no  communication  between  the  vagina  or  uterus  and  rec- 
tum, though  before  death  the  color  of  the  urine  had  led  to  its 
supposed  existence.  No  other  malformation  than  that  of  the 
rectum  existed. — {Op.  cit.  p.  511.) 

Case  C. — In  the  case  of  a  new-born  infant  which  died  six 
days  after  birth,  M.  Littre  found  the  rectum  normal  both  be- 
low and  above  an  obstruction  composed  of  a  fibrous  mass  an 
inch  in  length.  This  obstruction  divided  the  rectum  into  two 
portions,  each  terminating  in  a  cul-de-sac. 

ISTo  operation  had  been  performed  in  this  instance. — {His- 
toire  de  VAcademie  Royale  des  Sciences  de  Paris.  Annee 
1710.  2>-  36.) 

Tliis  was  the  case  that  suggested  to  M.  Littre  the  idea  of 
creating  an  abdominal  artificial  anus.     [  Vide  Chapter  Xl.'\ 


In  addition  to  the   authors  already  named,  the  following 
may  be  referred  to,  as  having  also  witnessed  cases  in  which 
the  rectum  was  imperforate  at  a  greater  or  less  distance  above 
a  well  formed  anus. 
Courtial.     Nouvelles   Ohservatlons  Anatomiques  sur   les  Os. 

p.  147.     Leide:  1704. 
Fourcade.     Revue  Medlcale  de  Paris.     Anfiee  1830.     tome 

IV.    p.  52. 
Cruvielhier.     Revue  Medicale  de  Paris.    Annee  1833.    to7ne 

II.  p.  422. 
Dupuytren.     Journal  Hehdornadaire  de  Medicine  de  Paris. 

Annee  1829.     tome  II.  p.  421. 
Colson.      Journal  Hehdomadaire   de    Medicine  de   Paris. 

Annee  1829.     tome  II.  p.  150. 
Bonn.     Papendorf.     op.  cit.    p.  253. 
Griraaud.     Journal  GenSrale  de  Medicine,     tome  XXIV. 

p.  238. 


THE   FOURTH   SPECIES   OF   MALFOltMATION.  199 

Tlic  following  cases  all  belong  to  this  the  tV)urth  species, 
and  should  be  so  classed.  Their  history  and  description,  for 
obvious  reasons,  will  be  given  in  the  chapter  on  Ahdombial 
Artificial  Anus.     [  Vide  Chapter  XI.'\ 

Casks  —  CCLXIII— CCLXVn— CCLXVIII  -CCLXXVII 
— CCLXXXIV— CCLXXXY— CCL  XXXVII. 


THE  FIFTH  SPECIES  OF  MALFORMATIOK 

S  E  C  T  I  O  X    I  . 
DESCRIPTION. 

1.  In  this  species,  the  anus  being  generally  either  absent, 
occluded  by  a  membrane,  or  existing  only  in  a  rudimentary 
state,  the  rectum  near  its  interior  extremity,  sends  off  ajnpe- 
lihe  prolongation  which  terminates  externally  in  a  preter- 
natural orifice  at  some  point  in  the  perinseum,  or  at  various 
points  beneath  the  urethra,  as  far  up  as  the  frsenum  prceputii ; 
at  the  labia  pudendi,  or  at  some  point  in  the  sacral  region. 

2.  The  rectum  sometimes  terminates  in  two  extremities  in 
the  perinaeal  region,  each  one  by  an  abnormal  anus,  both  per- 
forming the  functions  peculiar  to  the  natural  anus,  and  situa- 
ted more  or  less  distant  from  each  other.  The  one  niay  be 
larger  than  the  other,  and  give  egress  to  the  greater  portion 
of  the  contents  of  the  bowels.  Dr.  Bushe  has  mentioned  such 
a  case.  [  Vide  Case  CXIII7\  Dr.  Green  also  relates  a  sin- 
gular instance  of  the  same  kind.     [  Vide  Case  CXIV.^ 

3.  These  adventitious  canals  of  the  rectum  differ  from  the 
ordinary  fistulous  passages  only  by  being  more  perfectly 
organized  ajid  being  entirely  free  from  induration.  They 
remind  me  verv  much  of  the  fistulous  sinus  which  the  rectum, 
in  order  to  relieve  itself  sometimes  sends  off  from  beyond  a 
permanent  stricture  of  that  intestine,  when  the  contraction 
exists  a  few  inclies  above  the  anus.      Tliey  may  be  regarded 

in   the  character  of  supplementarv  conduits,   and  cannot  be 

(200) 


TIIK    Firm    SPECIES    OF   MALFOKMATIOX.  201 

considered  Jis  either  lui  arrest  of  development,  nor  a-;  an 
excess  of  development,  but  as  a  purely  i>atliolo<^ical  tV.ruia- 
tion. 

4.  In  some  of  these  instances  tlie  conjjenital  eloniration  of 
the  rectum  in  the  form  of  a  fistulous  sinus  is  covered  merely 
1)}'  the  thin  skin  of  the  perinreum^  so  that  the  meconium  can 
be  seen  throuirh  it,  and  the  course  of  the  canal  traced  to  its 
termination.  The  celebrated  M.  Cruveilliier  reports  a  very 
interesting  case  which  1  have  presented  in  fnll  translated 
from  the  original.     [Vide  Case  CV.'] 

5.  A  few  instances  are  recorded  in  which  the  sacrum  was 
found  to  be  so  congenitally  malformed,  so  very  deficient  as  to 
permit  the  extremity  of  the  rectum  to  perforate  it,  and  open 
externally  in  an  abnormal  anus.  M  M.  De  La  Faye  and 
Lacoste  mention  cases  of  this  character.     [  Vide  Cases  CX- — 

cxi—Gxn:\ 

6.  Papendorf,  as  well  as  others,  has  classed  all  such  cases, 
I  am  here  considering,  with  those  of  his  species  which  he 
denominates — "  Atresia  Ani  Vesicalis —  UrethraUs —  Vagi7i- 
alis,''^  but  as  the  rectum  in  these  cases  terminates  externally, 
and  has  no  communication  whatever  with  the  genito-urin- 
ary  jiassages,  they  cannot  therefore  be  so  classed  with  propri- 
ety. I  will,  however,  have  occasion  again  to  refer  to  these 
accidental  canals  of  the  rectum  in  the  next  chapter,  in  whicli 
I  will  show,  that  they,  instead  of  opening  externally,  by  an 
abnormal  anus  as  in  these  cases,  do  sometimes  open  internally 
into  the  genito-urinary  passages  by  an  abnormal  anus. 

7.  The  prognosis  in  these  cases  is  generally  favorable. 
Should  the  accidental  canal  be  tolerably  large  with  a  corres- 
ponding orifice,  the  little  patient  may  live  for  some  time  in 
comparative  comfort,  if  the  other  requisites  of  life  are  pres- 
ent, but  as  soon  as  the  diet  of  the  child  is  changed,  and  the 
stools  become  more  consistent  or  hard,  and  are  voided  with 
greater  difficulty,  the  troubles  commence  which,  unless 
relieved  by  an  operation,  must  sooner  or  later  end  in   death. 


202  THE   FIFTH   SPECIES    OF   MALFORMATION. 

8.  Ill  those  cases  whicli  the  anus  is  occluded  by  a  simple 
membrane  only,  the  operation  almost  always  succeeds.  On 
the  contrary  wlien  this  membrane  is  very  thick,  or  when 
there  is  no  trace  of  an  anus,  and  a  considerable  portion  of  the 
inferior  extremity  of  the  rectum  deficient,  the  operation  of 
course  is  much  more  difficult,  and  the  result  more  uncertain. 


SECTION    II. 

THE  TREATMENT. 

The  indication  to  be  observed  in  the  treatment  of  those 
cases  of  this  species  which  occur  in  the  male  subject,  is  to 
isolate  completely  the  accidental  canal  from  the  end  of  the 
rectum,  and  to  establish  the  artificial  anus  in  the  perinseum 
at  the  normal  site  of  the  anus.  The  jyijpe-like  passage  being 
separated  from  the  rectum  should  now  be  treated  as  an  ordin- 
ary anal  fistula,  by  inserting  into  it  a  fine  silk  ligature  and  grad- 
ually destroying  its  wall ;  or  by  incising  it  with  a  small  nar- 
row sharp-pointed  bistoury,  guided  by  a  flexible,  grooved 
director. 

I  will  now  give  the  method  which  Professor  Dieffenbach 
proposes  for  the  treatment  of  those  cases  which  occur  in  the 
male  subject. 

The  Process  of  Dieffenhach.  At  the  place  of  the  normal 
anus  a  small  oval  flap  of  integument  is  incised,  being  held 
wnth  the  bull-dog  forceps,  the  skin  is  dissected  away  with  a 
small  sharp  scalpel.  After  its  removal,  the  wall  of  the  rec- 
tum becomes  visible,  whicli  must  not  be  incised.  One  quar- 
ter of  an  inch  in  front  of  this  longitudinal  wound  and  towards 
the  commencement  of  the  scrotum,  a  vertical  incision  is  made 
in  the  raphe  by  means  of  a  fold,  about  one-quarter  of  an  inch 
long  and  deep  enough  to  reach  the  prolonged  rectum  at  this 
point.     The  cellular  tissue  is  now  separated  from  each  side  of 


THE   FIFl'n    SPECIES    OF   MALFOUMATFOX.  203 

the  rectiun,  or  a  large  probe  is  introduced  beneath  the  rectal 
prolongation,  and  mIiIcIi  is  completely  divided  \\i\]\  scissors 
in  a  direction  vertical  to  its  axis.  Then  by  the  crucial  wound, 
the  free  end  of  the  rectum  is  seized  with  the  bull-dog  forceps 
and  is  drawn  into  the  oval  wound  designed  for  the  Jiiud  open- 
ing ;  after  having  completely  separated  it  IVom  its  cellular 
adhesions,  the  end  is  brought  througli  the  opening,  and  by 
means  of  six  points  of  suture  the  edges  of  the  intestine  are 
united  with  the  cutaueous  edges  of  the  oval  wound.  Tlie 
fsecal  matter  having  been  expelled,  there  is  passed  into  the 
isolated  and  now  abandoned  end  of  the  intestine,  by  means  of 
a  large  eyed  probe,  a  coarse  cotton  thread,  the  ends  of  which 
are  tied  with  a  knot,  and  the  wound  is  then  covered  with  lint. 
The  formation  of  the  anus  is  now  perfect,  and  is  soon  followed 
by  healthy  cicatrization  of  the  wounds.  The  useless  anterior 
extremity  causes  indeed  some  trouble  by  means  of  its  mucous 
lining,  but  it  requires  little  attention  until  the  effects  of  the 
first  operation  are  overcome.  A  caustic  crayon  may  be  passed 
througli  the  canal,  or  a  large  meche  of  lint  covered  with  some 
irritating  ointment  may  be  introduced,  and  after  remaining  in 
some  time,  it  may  be  removed  and  perfect  compression  estab- 
lished, by  means  of  lint  and  strips  of  adhesive  plaster.  If 
after  all  this  the  obliteration  of  the  canal  is  not  effected,  it 
may  be  incised,  and  in  this  way  the  object  attained.  {Opera- 
tive Chh'urgle.  Band.  I.  S.  675.    Lipzig :  1845.) 

Dieffenbach  successfully  executed  this  operation  upon  two 
male  children.     [  Vide  Cases  CIII^CIVJ] 

Dr.  Friedberg  has  also  projDOsed  a  method  of  operating  in 
such  cases,  which  differs  somewhat  from  that  of  his  illustrious 
coimtryman  Dieffenbach.  This  operation  he  successfully  exe- 
cuted in  the  highly  interesting  case  of  the  child  Albert  M . 

As  this  case  fully  illustrates  Dr.  Friedberg's  method  of 
operating,  I  have  given  it  entire,  translated  from  the  French, 
being,  as  I  remarked  before,  unable  to  obtain  a  German  copy 
of  his  valuable  essay.     [Vide  Case  CJlVII.] 


20  i  THE   FIFTH   SPECIES    OF   MALFORMATION. 

Witli  regard  to  tlie  operation  of  Dieifenbacli,  Dr.  Friedberg 
says: 

"  In  the  case  of  Albert  M ,  I  thought  best  to  adopt  a 

method  somewhat  diflt'erent  from  that  of  Dieffenbach,  and 
which  attains  the  end  w'ith  greater  simplicity,  and  may  be 
employed  in  cases  of  union  of  the  rectum  to  the  bladder,  ure- 
thra and  vagina ;  but  as  the  method  of  Dieffenbach  is  distin- 
guished by  the  tiict  that  when  the  skin  and  cellular  tissue  are 
removed,  the  rectal  wall  is  visible,  it  w^ould  not  answer  in 

cases   such   as   that  of  Albert  M ,  in  which  the  closed 

extremity  of  the  rectum  is  very  high  up,  and  since  this  fact 
cannot  always  be  determined  before  the  operation,  it  is  23refer- 
able  to  perform  it  in  such  a  manner  as  will  be  adapted  to  any 
possible  condition.  AVhen  the  rectum,  interrupted  in  the 
cavity  of  the  pelvis,  sends  oiF  a  canal-like  prolongation  open- 
ing into  the  bladder,  or  the  vagina,  or  is  prolonged  tOM^ards 
the  exterior,  passing  above  the  position  of  the   normal  anus, 

and  opens  near  the  scrotum,  (as  in  the  case  of  Albert  M ) 

or  in  the  penis,  I  should  perform  the  operation  as  I  have 
already  stated  above  in  ordinary  cases  of  anal  imperforation. 

I  shouhl  cut  the  canal  as  I  did  in  Albert  M ,  if  it  were 

found  in  the  viciuity  of  the  perinseum ;  in  a  contrary  case  I 
should  not  trouble  myself  about  the  formation  of  the  anus,  but 
rather  atteud  to  the  obliteration  of  the  canal,  which  object  we 
may  hope  to  effect  by  diverting  from  it  the  passage  of  faecal 
matter.  The  obliteration  may  be  rapidly  effected  from  the 
point  of  departure  from  the  rectum,  as  the  post-mortem  of 

Albert  M clearly  showed,  but  if  it  should  be  attended 

with  considerable  delay,  I  should  attempt  cauterization  by 
means  of  a  "wire  heated  to  a  red  heat  by  electricit3^"  iOp.  cit.) 

Ill  the  formation  of  the  artificial  anus  in  those  cases  in  which 
the  rectum  terminates  by  an  abnormal  orifice  at  the  labia 
pudendi,  the  vulva,  &c.,  tlie  short  accidental  passage  should, 
if  possible,  be  obliterated  without  dividing  the  septum  sepa- 
rating the  artificial  from  the  abnormal  anus,  as  the  division 
of  the  circular  fibres  of  the  sphincter  going  to  the  vagina, 
and  perhaps  the  incontinence  of  the  fseces  consequent  upon 
the  section  of  the  canal,  might  be  of  serious  consequence  ever 
after.  Friedberg,  however,  does  not  at  all  fear  any  evil  con- 
se(piences  to  follow  the  complete  incision  of  the  canal.  He 
says  that  if  it  is  cut  and  projjerly  treated,  it  will  granulate  and 


TiriC    FIKTII  Sl'KCIKS    OK    MALFOItMATK  >\,  205 

ciciilrizc,  and  this  will  the  more  ivadilv  Im11..w  if  th(;  knees  of 
tlie  chikl  lire  honnd  together;  and  if  the  divided  halves  of 
tlie  external  spliincter  tini  muscle  are  united  l)y  a  Jiealthy 
cicatrix,  tliere  is  no  cause  for  fear  as  to  the  functions  of  that 
muscle.  1  confess,  however,  that  I  should  have  fears,  ant  I 
would  decidedly  prefer  to  ohliterate  tlie  canal  hj  the  "  Gal- 
vano-Causiiti'''  method  of  Middeldorpfi*,  of  Breslau.  This  would 
be  attended  with  no  danger,  and  would  most  certainly  succeed. 
Dr.  Friedberg  himself  recommends  this  method  in  otlier 
cases,  in  which,  in  my  opinion,  it  is  not  as  applicable  as  in 
these. 

In  cases  of  this  character  some  surgeons  recommend  tlie 
practice  of  M.  Yicq  d'Azyr  in  the  instances  in  which  the  rec- 
tum opens  into  the  vagina.  His  operation  is  certainly  vei-y 
simple  and  easy  of  execution,  but  is  liable  to  the  objection  1 
have  already  stated. 

The  Process  of  Vicq  D^Azyr.  A  straight  bistoury  guided 
by  a  grooved  sound  introduced  through  the  fistulous  opening 
and  passage  into  the  rectum,  and  directed  from  before  back- 
ward, or  from  the  peringeum  to  the  coccyx,  or  from  above 
downward,  would  divide  all  the  tissues  which  had  caused  the 
deviation.  A  canula  fixed  in  the  rectum  near  the  posterior 
angle  of  the  wound,  would  enable  the  solution  of  continuity 
in  front  to  cicatrize,  and  the  matters  to  re-acquire  their  nor- 
mal direction.  {MoWs  Velpeau.  Vol.  III.  p.  1087.  New 
York:  1817.) 

In  those  cases  in  which  the  rectum  terminates  by  two 
abnormal  apertures  in  the  peringeum  at  the  same  time,  differ- 
ing in  size,  and  more  or  less  separated  from  each  other,  Mr. 
Asliton,  of  London,  says — "  Surgical  interference  will  not  be 
required  if  either  opening  be  of  suflicient  size  for  the  free  dis- 
charge of  the  fseces ;  but  if  both  be  so  small  that  the  process 
of  defecation  cannot  be  properly  performed,  the  septum 
between  them  must  be  divided,   or  that  which  corresponds 


206  THE   FIFTH    SPECIES    OF   MALFOKMATION. 

most  clearly  to  tlie  natural  position  of  tlie  anus  must  be 
dilated  by  pressure,  and  by  incision  if  necessary.  (A  Trea- 
tise on  the  Diseases,  I)ijuries,  and  Malforinations  of  the  Rec- 
tum and  Ames.    Chapter  XIX.  p.  337.     London :  1854.) 

In  tliose  cases  in  wbicli  the  rectum  terminates  by  an  abnor- 
mal anus  in  the  sacral  region,  I  am  not  aware  that  any  treat- 
ment has  ever  been  proposed. 


SECTION    III. 

CASES    AND     REMARKS. 

Case  CI. — Fabricius  of  Ilildanus  mentions  the  case  of  a 
child  which  had  an  abnormal  anus  situated  at  the  root  of  the 
penis,  the  orifice  of  which  was  about  the  size  of  a  pea,  and 
from  which  meconium  and  gas  escaped.  In  this  instance  there 
was  no  trace  of  an  anus,  a  thick,  strong,  and  hard  membrane 
covering  the  place  it  should  have  occupied,  and  extending 
itself  forward  to  the  abnormal  opening  at  the  root  of  the  penis. 
The  operation  of  incising  this  membrane,  was  performed  on 
the  sixth  day,  and  the  result  was  a  cure. — {Ohservationum  et 
Curationum  Chirurgicarum.  Centuria.  Centur.  I.  Ohserv. 
76.  J).  54.     Basil :  1606.     JPolia.) 

Case  CII. — Dr.  George  Tobie  Durr,  a  physician  of  Augs- 
burg, relates  the  case  of  a  male  child  having  an  imperforate 
anus,  in  which  the  membrane  that  closed  the  anus  was  pro- 
longed forward  to  the  anterior  part  of  the  perinoeum,  in  which 
was  a  small  opening  through  which  the  meconium  drained  ofi". 
Two  months  after  the  birth  of  the  child,  Durr  performed  the 
operation  of  incising  this  membrane  up  to  the  natural  place 
of  the  anus.  The  faeces  were  voided  in  abundance  and  the 
cure  was  ultimately  completed. — {Miscellanea  curiosa,  sire 
ephem..  acad.  natur  eurlosor.  decur.  II.  ami.  VI.  ohserv.  62. 
p.  3.  1668.) 

Cases  CIII. — CIV. — Dieifenbach  mentions  the  two  follow- 
ing cases  of  imperforation  of  the  anus  attended  with  a  prolong- 
ation of  the  rectum  opening  in  the  perinreum. 

He  observed  this  elongation  of  the  rectum  in  two  male 


THE   FIFTH    SPECIES   OF   MALFOUMATIOX.  207 

cluldren,  one  a  few  weeks,  and  tlic  otlier  two  munilis  old. 
In  the  first,  the  somewhat  siiiull  unal  orifice  was  lui'iucd  in 
the  posterior  part  of  the  scrotum,  lii  tlie  second  it  opened  on 
the  anterior  face  of  the  scrotum.  In  tliis  last  case  tlie  (■lonji:- 
ated  portion  of  tlie  rectum,  conti"actin<^  t(.»wards  the  anterior 
part,  was  nevertheless  hirge  enou<2;h  to  admit  an  elastic  cathe- 
ter of  medium  size.  In  both  children  the  tVbces  were  voided 
throug-h  the  fistulous  canal  and  ahnornuil  anus  with  ]>ut  little 
dilliculty,  and  in  each  case  iJieffenbach  operated  with  com- 
plete success. — {Operative  Chirurgie.  Band.  I.  S.  676. 
Ze/j)2i(/:  1845.) 

Diefi'enhach  was  the  first  surgeon  who  proposed  '■[Anap- 
lasty "  by  lengthening  the  rectum  in  the  male  subject. 

Case  CY. — Tlie  celebrated  M.  Cruvielhier  gives  the  details 
of  a  highly  interesting  case  of  a  male  infant  who  presented  a 
congenital  imperforate  anus,  with  a  prolongation  of  the  rectum 
in  the  shape  of  a  narrow  fistulous  passage  formed  in  the  very 
substance  of  the  raphe  scroti,  and  terminating  in  an  abnormal 
oj)ening  immediately  below  the  meatus  urinarius. 

"  A  woman  twenty -nine  years  of  age,  who  was  pregnant 
the  second  time,  and  who  w^as  an  invalid  and  considerably 
a3dematous  during  the  second  montli  of  her  pregnancy,  was 
delivered  on  the  sixth  day  of  July,  1828,  at  the  Lying-in 
ilospital,  of  a  male  child  at  full  time — living  and  presenting 
the  following  peculiarities.  The  child  was  poorly  developed, 
and  afflicted  with  marasmus ;  it  was  besides  reduced  to  a 
purely  vegetative  life  ;  its  body  was  cold  ;  its  skin  discolored  ; 
its  limbs  contracted  ;  it  uttered  nothing  but  dull  groans,  and 
with  the  exception  of  some  slight  spasmodic  contractions,  it 
was  nearly  motionless. 

"  There  was  no  anus,  but  at  the  situation  which  the  normal 
anus  should  occupy,  there  was  an  elevation  of  the  skin  caused  by 
an  accumulation  of  the  meconium.  Tlie  raphe  was  prominent 
and  knotty,  and  it  was  easily  observed  that  a  narrow  canal 
penetrated  it,  as  it  was  distended  with  meconium  which  could 
be  seen  through  the  thin  skin  which  covered  it.  This  canal 
ultimately  terminated  under  the  glans  penis  in  an  abnormal 
opening  which  gave  issue  to  meconium. 

"  An  incision  was  made  into  the  raised  portion  of  skin  cor- 
responding to  the  anus ;  a  great  quantity  of  meconium  es- 
caped ;  nevertheless  the  child  remained  in  the  same  condi- 
tion ;  cold,  motionless,  discolored,  and  voiding  by  the  nose, 
the  milk  and  sweetened  water  which  were  introduced  by  the 
mouth.     It  was  momentarily  expected  to  die,  and  yet  its  life 


208  THE   FIFTH   SPECIES    OF   MALFORMATION. 

^vas  prolonged   to   the   fii\eentli   of  Julj,  nine  days  after  its 
birth. 

"  Autopsy.  It  was  found  that  the  rectum  terminatecl  in  a 
cul-de-sac,  that  it  was  distended  by  meconium  and  gas,  and 
of  sufficient  size  to  admit  the  index  finger.  Near  its  termin- 
ation it  gave  off  an  accidental  canal,  very  narrow  and  lined 
with  a  mucous  coat.  This  canal  at  first  directed  its  course 
from  behind  forward,  and  from  above  downward  across  the 
fatty  tissues  of  the  perinaium,  rea<?hed  the  posterior  extremity 
of  the  raphe  through  the  body  of  which  it  continued,  and 
finally  opened  under  the  glans  penis.  This  opening  readily  ad- 
mitted a  slender  probe,  allowing  it  to  pass  the  whole  length  of 
the  canal.  There  was  no  communication  between  the  rectum 
and  the  bladder,  between  the  rectum  and  the  urethra,  nor  be- 
tween the  rectum  and  vagina.  [  Vide  PlateVIII.  Figs.  1,2,3,] 

'•■The  extraordinary  symptoms  that  presented  themselves  in 
this  case  could  not  properly  be  attributed  to  the  malformation 
just  noticed.  Tliere  must  have  been  a  remarkable  deformity 
of  the  organs  of  circulation  and  respiration.  There  was  a  per- 
ceptible defect  in  the  formation  of  the  blood,  but  it  was  diffi- 
cult to  define  exactly  what  it  was.  An  injection  made  by  the 
left  carotid  artery  filled  the  whole  circulatory  system,  arteries 
and  veins,  and  returned  through  the  mouth  and  the  nostrils." 
— {Anritomie  Pathologique  du  Corps  Ilumain.  tome  I. 
Livraison  I.  Planche  VI.  Figs.  6,  7,  8.  Bruxelles : 
1833,  1831.) 

Case  CVI. — Mr.  J.  F,  South,  one  of  the  surgeons  to  St, 
Tliomas'  Hospital,  London,  reports  the  following  case  : 

"  I  had  under  my  care,  very  many  years  ago,  a  case  of  im- 
perforate anus  similar  to  that  mentioned  by  M.  Cruvielhier. 
{Anat.  Pathol.  Uvr.  I.  pi.  V.fig.  6.)  At  the  time  of  birth 
there  was  not  any  opening,  but  a  slight  puckering  marked 
the  place  of  the  anus,  and  this  was  protruded  each  time  tlie 
child  cried.  In  front  of  the  scrotum,  and  in  the  track  of  the 
raphe,  as  it  passed  on  to  the  prepuce,  was  a  small  aperture, 
just  large  enough  to  admit  the  entrance  of  a  probe,  and  from 
it,  when  the  child  cried,  a  small  quantity  of  meconium  passed, 
I  cut  upon  the  puckered  skin,  but  it  was  full  an  inch  before 
the  rectum  could  be  reached,  and  I  then  opened  it  sufficiently 
to  admit  a  large  urethral  bougie,  and  the  meconium  readily 
escaped.  A  probe  introduced  at  the  opening  before  the 
scrotum,  passed  along  a  canal,  beneath  the  urethra,  through 
the  }>eriuaeum,  becoming  larger  and  larger  as  it  approached 
the  rectum,  in  which  it  terminated.  No  bougie,  or  au}^  thing 
else,  was  left  in,  as  I  thouglit  keeping  the  bowels  loose,  would 


THE    FIKTII    8PKCIES    OF   MALKOUMATIOX.  2<)0 

have  l)oen  snffici(Mit  to  ])rov(Mit  union  ;  Iiowcnht,  in  tlu;  courBe 
of  a  fortiiig'lit  the  wound  had  closed,  and  no  motion  was 
passed  except  hy  tlie  aperture  in  front  of  the  scrotum.  1 
therefore  luid  to  cut  into  tlie  rectum  a<i;ain,  and  a  ])ioc^^  of 
l)oui;-ie  was  then  introduced,  to  he  woi-n  consfantiv,  l)Ut 
removed  three  or  four  times  a  (hiy,  for  emptjiiii;  the  l)owels. 
This  went  on  very  well  for  a  short  time,  hut  proha])ly  from 
iiei;li2;ence,  the  scar  contracted,  and  at  tlie  end  of  three 
nutntlis,  the  anal  openin<>;  wonhl  not  a(hnit,  even  the  end  of  a 
prohe.  The  scar  was  therefore  again  di\ick'd,  and  a  hirger 
bougie  introduced  and  worn  for  a  fortnight ;  after  which 
a  sliort  pew^ter  pipe,  about  the  thickness  of  the  little  ^nger, 
with  a  circular  sliouldei"  to  pi-event  it  slipping  entirely  into 
the  gut,  was  introduced,  so  that  the  motions  might  pass  con- 
tinually by  it,  and  the  opening  be  established.  Two  months 
after,  the  pipe  having  slippecl  out,  and  been  neglected,  the 
opening  had  again  closed,  and  again  required  enlarging  with 
the  kiufe  to  re-admit  the  tube.  The  parent's  negligence  again 
compelled  the  dilatation  of  the  aperture  with  the  knife,  and  a 
large  bougie  was  directed  to  be  passed  frecpiently.  I  did  not 
again  see  liim  nntil  he  was  seven  years  old,  wdien  he  was  a 
well-grown  boy,  but  with  an  enormously  distended  belly. 
The  anus  continued  open,  though  not  very  sufiiciently,  and 
the  oiiiice  before  the  scrotum  was  still  open,  and  occasionally 
motion  passed  by  it.  I  was  desirous  of  removing  this  unnatu- 
ral canal,  but  the  mother  was  averse  to  it,  and  the  child's 
unhealthy  appearance  did  not  lead  me  to  expect  that  he  would 
live  very  long.  I  had  entirely  forgotten  him,  when  eleven 
years  after,  he  being  then  eighteen  years  old,  I  was  surprised 
on  seeing  him  a  line  healthy  young  man,  who  said  he  was 
the"  person  on  whom  I  had  previously  operated.  The  appear- 
ance of  the  anus  could  be  compared  to  nothing  else  than  a 
bullet-hole  in  a  board  ;  he  said  he  had  no  difficulty  in  passing 
or  retaining  his  motions  ;  but  it  was  quite  evident  from  his 
linen,  that  there  was  a  continued  oozing.  The  opening  in 
front,  instead  of  being  near  the  frcenum  prmputii,  was  now 
close  to  the  scrotum,  and  a  small  quantity  of  stool  occasionally 
escaped  from  it.  On  examining  more  closely,  I  found  the 
anal  orifice  completely  tilled  with  a  protruded  portion  of  the 
lining  of  the  rectum ;  it,  however,  offered  no  obstruction  to 
the  linger,  which  readily  passed  up  as  far  as  the  knuckle,  and 
was  received  into  the  large  cavity  full  of  feculent  matter,  and 
running  forward  along  the  perinseum,  beneath  the  membranous 
part  aiid  bulb  of  the  penis,  to  the  back  of  the  scrotum  where 
the  canal  narrowed,  and  w<:)uld  only  admit  the  linger ;  wdth 
this  the  opening  before  the  scrotum  communicated.  It  was 
14 


210  THE   FIFTH    SPECIES    OF   MALFORMATION. 

curious,  in  this  case  that,  although  there  was  an  entire  absence 
of  tlie  sphincter  muscle,  the  stools  did  not  pass  involuntarily ; 
the  protruded  fold  of  the  internal  membrane  seemed  to  form 
a  valve  which  prevented  ordinarily  the  escape  of  the  stool, 
and  compensated  the  deficiency  of  the  sphincter.  I  proposed 
to  him  the  removal  of  the  continuation  of  the  bowel  into  the 
perinffium,  but  he  would  not  submit  to  any  operation.  I  have 
not  seen  him  for  the  last  eleven  years."  {Saint  Thomas' 
Jlosjoital  Bejyorts^  p.  121.  London:  1836.  Also  English 
Translation  of  CJieliiCs  System  of  Surgery^  Amer.  Ed.^  Vol. 
IILp.  39.     'Philadelphia:  1847.) 

Case  CVII. — M.  Monad  gives  an  instance  of  a  male  child 
having  an  imperforate  anus,  the  rectum  being  prolonged  in 
the  form  of  a  fistulous  canal  to  within  a  short  distance  of  the 
glans  penis,  where  it  terminated  in  an  abnormal  anus. 
{JVouvelle  Bibliotheqice  Medicale.  tome  II.  2>-  4-17.  Paris  : 
ls29.) 

Cases  CVIII — CIX. — M.  Fristo  mentions  the  cases  of  two 
infants  having  each  an  abnormal  anus.  In  one  the  rectum 
opened  in  the  loins,  and  in  the  other  it  opened  ujDon  the  dor- 
sum of  the  penis.  {Mott's  Velpeau.  Vol.  Ill  j;.  1086.  JVev^ 
York:  1847.) 

Cases  CX — CXI. — M.  De  La  Faye  gives  the  description 
of  two  children,  in  both  of  which  there  was  found  an  abnor 
mal  anus  in  the  sacral  region,  the  orifice  in  each  being  suffi- 
ciently large  to  admit  the  little  finger.  In  one  of  the  cases  a 
portion  of  the  rectum  passed  through  the  opening  in  the 
sacrum,  and  formed  a  kind  of  hernia.  {Principes  de  Chirur- 
gie,  p.  358.    Paris  :  1811.) 

Cask  CXII. — M.  La  Coste  mentions  the  case  of  an  infant 
in  whom  the  rectum  perforated  the  sacrum  and  formed  an 
aljnormal  anus,  througli  which  the  fteces  passed.  (Bulletin 
de  la  Societe  Medicale  d'' Emulation  de  Paris.  Octohre,  1822, 
p.  417.) 

Cask  CXIII. — Dr.  Bushe  mentions  a  case  in  which  two 
anal  apertures  existed  at  the  same  time.  He  says  :  "  About 
four  years  ago,  Dr.  AVilliam  Power  very  kindly  allowed  me 
to  examine  a  fine  healthy  child,  a  few  days  old,  in  whom  the 
rectum  terminated  by  two  extremities,  one  being  placed  a 
little  more  anterior  than  natural,  while  the  other,  though  also 
on  the  median  line,  was  situated  nearly  an  inch  further  back. 


THE  Firni  species  of  mai.foumatiox.  211 

Tliis  last,  which  was  tlie  smaller  of  the  two,  did  not  discliar<^o 
more  than  one-third  of  the  fu'ct's,  and  as  nearly  as  I  could 
ascertain  with  a  probe,  M'as  about  one  inch  and  a  half  in 
length."  {A  Treatise  on  the  Mai  for  mat  ions,  Injuries  and 
Diseases  of  the  Rectum  and  Anits,  jp.  44.   JSfew  York:  1S37.) 

Case  CXIY. — Dr.  W.  A.  Green  reports  the  following  sin- 
gular case  of  extensive  congenital  deformity  : 

''I  was  called  to  Mrs.  L ■  on  Monday,  January  5th, 

1858.  She  had  been  in  labor  with  her  second  child.  Nothing 
nnusual  occnrred  during  gestation  or  paturition.  She  gave 
bij'th  to  a  child,  over  the  average  size,  which  cried  lustily, 
seeming  to  indicate  that  every  function  was  regularly  and 
properly  performed.  Upon  a  close  examination,  the  following 
deformities  were  found  to  exist :  The  spine  began  a  curvature 
at  the  snperior  third  of  the  cervical  vertebrte,  in  a  direction 
toward  the  right  hypochondrium,  to  the  top  of  the  sacrum. 
The  concavityof  this  curvature  w^as  filled  with  two  or  three 
sac-like  appendages,  containing,  apparently,  a  fluid  and  gas. 
moveable  and  compressible.  'A  want  of  the  spinous  pro- 
cesses of  three  or  four  contiguous  vertebrae,  is  not  a  very 
uncommon  species  of  monstrosity.'  '  This  constitutes  spina 
lifida^  'There  is  usually  a  soft,  fluctuating  tumor,  in  the 
malformed  bones,  caused  by  water  contained  within  the  sheath 
of  the  spinal  marrow.'  [  Vide  Ramshothani' s  Obstetric--<. 
{Keating.)  Appendix  J/,  p.  622.]  Below,  upon  each  side 
of  the  sacrum,  were  tw^o  appendages,  resembling  the  mamma' 
of  woman.  In  front,  between  the  point  where  the  umbilicus 
was  attached,  and  the  symphisis  pubis,  was  a  protrusion  of 
intestines,  within  the  peritoneal  sac,  reducible  by  pressure, 
but  returning  wdien  removed.  Immediately  under  this 
hernia,  the  urine  trickled,  continuously,  from  two  or  three 
small  openings,  which  could  not  be  entered  by  the  smallest 
probe.  Below  this,  and  hanging  pendant  from  the  middle  of 
the  symphisis  pubis,  were  the  testicles,  perfectly  formed. 
There  was  no  trace  nor  any  portion  of  the  penis.  Behind  the 
symphisis  pubis,  in  juxta-contact,  and  at  the  extreme  anterior 
portion  of  the  perinseum,  was  an  anus,  well  formed,  through 
which  the  faeces  passed.  About  an  inch  and  a  half  behind 
this,  at  the  point  of  the  os  coccygis,  was  another  anus,  which, 
upon  examination,  proved  to  be  imperforate — a  cul-de-sac. 

"The  face  of  the  inftrnt,  when  first  born,  was  perfectly 
black,  but  is  changing  to  a  mulberry  hue.  Numerous  marks 
are  upon  its  body,  such  as  are  frequently  seen  upon  children. 
Every  other  portion  of  the  child  seems  perfectly  and  synmiet- 
rically  developed.     Its  bowels  are  regular,  it  is  healthy,  and 


212  THE   FIFTH    SPECIES    OF    MALFORMATION. 

rapidly  growing.  The  complete,  entire  absence  of  tlie  penis, 
or  any  portion  of  it — the  unusual,  unheard-of  positions  of 
the  anus,  testicles,  and  anomalous  passage  of  the  urine,  are 
extremely  remarkable  and  interesting.  The  bladder  has  no 
urethra,  through  which  to  pass  its  urine,  so  these  apertures 
must  come  in  direct  contact  with,  and  even  enter  the  fundus 
of  the  bladder,"  (Southeni  Medical  and  Surgical  Journal. 
Augusta,  Ga.,  1858.) 

Case  CXY. — M.  Bouisson  of  IVIontpellier,  relates  a  case  of 
this  cono-enital  vice  of  conformation  which  was  observed  in 
the  practice  of  Delmas. 

A  child  was  brought  to  Delmas,  from  seven  to  eight  days 
old,  which  was  born  with  an  imperforation  of  the  anus,  and 
with  a  small  corrugated  opening,  red  and  excoriated,  which 
existed  about  half  an  inch  from  the  median  line  on  the  side  of 
the  right  nates.  Through  this  opening  the  fsecal  matters  were 
constantly  oozing,  the  liquid  state  of  which  allowed  their 
rather  easy  escape.  It  constituted  a  true  congenital  listula  of 
the  anus,  on  wdiich  Delmas  operated,  at  the  same  time  he 
remedied  the  imperforation  by  an  incision.  Tlie  obstructing 
membrane  was  cutaneous,  mucous,  with  conservation  of  the 
sphincter.  M.  Delmas  incised  it,  introduced  his  linger  into 
the  rectum,  when  he  recoguized,  at  an  inconsiderable  height, 
the  end  of  a  grooved  probe  introduced  into  the  accidental 
opening.  The  operation  was  performed  as  in  the  adult,  and 
followed  by  the  rapid  recovery  of  the  infant. — {These  de  Con- 
cours  de  Paris.     Annee  1851.) 

Case  CXYI. — A  similar  case  in  every  respect  to  that  of 
Delmas'  was  communicated  to  the  Chirurgical  Society  of 
Paris  in  1850,  by  M.  Denonvilliers.  This  surgeon  operated  suc- 
cessfully both  on  the  anal  occlusion  and  the  fistulous  sinus  in 
this  case. — {Practical  Treatise  on  the  Diseases  of  Children, 
1)1/  M.  Boiichut.  Bird^s  English  Version,  ]).  516.  London  : 
1855.) 

Case  CXYII. — Dr.  Friedberg  reports  the  following  highly 
interesting  case  of  imperf  n-ation  of  the  anus,  accomjDanied  by 
a  fistulous  prolongation  of  the  rectum  opening  into  the  pos- 
terior wall  of  the  scrotum. 

"  Albert  M — ,  the  fifth  child  of  a  healthy  woman,  was  born 
on  the  fourteenth  day  of  Jnly,  1852,  at  nine  o'clock  P.  M., 
by  natural  labor.  During  the  following  night  and  day  the 
child  look  the  breast  with  reluctance,  even  from  the  first.  It 
passed  urine   frequently,  but  without    any  mixture  of  faecal 


TIIK    MI'JU    SI'ECIKS    OF    MALFORMATION.  213 

matter.  Three  days  uWor  birtli,  the  cliild  liavuig  as  yet  had 
no  reii;iihir  stool,  and  excitini^  tlie  anxiety  of  the  niotlier  l)y 
its  cries  and  restlessness,  slie  examined  the  perinanim  and 
found  in  the  posterior  wall  of  the  scrotum  a  small  (»peiiiii;;'  in 
])lace  of  an  anus,  and  thi'oui;-]i  which  a  little  meconiuiri  passed 
when  the  child  made  violent  straining  ett'orts.  The  physician 
called  in  on  the  following  day,  in-escribed  warm  cataplasms 
upon  the  abdomen,  and  syrup  of  rhubarb  internally.  From 
lime  to  time  the  abdomen  became  distended,  "the  child 
groaned  and  made  efforts  to  stool,  until  fsecal  matter  passed 
which  soon  became  yellow.  Although  frequently  put  to  the 
breast,  it  sucked  very  little,  but  slept  in  a  very  unquiet  man- 
ner, and  from  the  fourth  week  it  began  to  waste  away  surpris- 
ingly. Towards  the  sixth  week  after  its  birth,  as  the  mother 
said,  there  occurred  a  remarkable  attack,  during  which  it  be- 
came pale  as  a  corpse,  very  restless,  breathed  almost  imper- 
ceptibly, drew  lip  its  knees,  and  seemed  to  the  mother  as  if 
dying.  This  attack  was  repeated  several  times  during  the 
two  following  weeks,  and  especially  as  the  mother  was  con- 
vinced, when  the  child  had  had  no  evacuation  for  several  hours. 
"  The  attending  physician  sent  for  me  on  the  nineteenth  of 
September,  1852,  to  make  a  more  complete  diagnosis.  The 
examination  gave  me  the  following  results.  The  child,  for  its 
age,  two  months,  was  very  small  and  reduced  to  the  last  de- 
gree of  emaciation.  The  saliva  was  of  a  yellow  color,  and  so 
was  the  wdiole  body,  especially  the  countenance  ;  the  eyes 
were  sunken  and  surrounded  by  a  greenish  blue  circle,  the 
voice  was  very  feeble,  and  the  cries  replaced  by  feeble  groans. 
The  abdomen  was  moderately  distended,  hard  and  sensitive. 
There  was  a  slight  malformation  of  the  penis  ;  in  fact  the  in- 
ternal orifice  of  the  canal  of  the  urethra,  opened  in  the  form 
of  a  cleft  about  three  lines  from  the  end  of  the  glans  penis. 
The  genital  organs  w^ere  quite  in  the  rear  of  their  normal  posi- 
tion. Three  or  four  lines  below  the  point  where  the  rectum 
terminated,  there  was  found  in  the  posterior  wall  of  the 
scrotum,  an  opening  with  its  border  turned  inward,  only  large 
enough  to  admit  a  small  sound.  I  introduced  such  an  instru- 
ment half  an  inch,  and  had  the  sensation  as  if  I  had  introduced 
it  into  a  cutaneous  canal  which  extended  no  further  in  that  di- 
rection ;  however,  as  I  had  seen  a  greenish  colored  matter 
pass  from  the  opening,  I  could  not  doubt  the  existence  of  a 
continuation  of  this  canal  uniting  it  with  the  intestine.  I  in- 
troduced a  whalebone  sound,  at  first  directly  upward,  then 
more  towards  the  rear,  in  the  direction  of  the  middle  of  the 
pelvis,  as  much  as  three  inches,  without  meeting  a  dilatation  of 
this  canal.     At  this  depth  the  sound  was  arrested  by  an  ob- 


214  THE    FIFTH    SPECIES    OF    MALFORMATION. 

strnction  sucli  as  caused  it  to  bend.  The  tuberosities  of  the 
ischium  projected  when  compared  with  the  remarkably  wasted 
condition  of  the  child,  and  seemed  to  be  pressed  close  to  each 
other,  so  that  the  space  which  separated  them  was  much  nar- 
rower than  usual.  The  coccyx  was  bent  quite  to  the  front ;  the 
perina3al  raphe  extended  as  far  as  the  coccyx  and  was  not  well 
marked ;  and  not  even  the  slightest  trace  of  an  anus  was 
found.  During  the  efforts  made  shortly  after  the  use  of  the 
catheter,  and  whilst  the  abdominal  walls  were  in  full  action, 
I  could  not  feel  any  fluctuation  in  the  perinsBal  region.  The 
eftbrts  were  followed  by  an  evacuation,  lasting  several  minutes 
and  passing  through  the  fistulous  opening,  and  also  by  an  ex- 
cretion of  urine  of  a  natural  color  flowing  by  the  external  ori- 
fice of  the  urethra.  Whenever  with  my  right  fore  finger 
placed  in  the  normal  position  of  the  anus,  I  pushed  the  perin- 
eum towards  the  pelvic  cavity,  and  with  the  left  hand  pressed 
the  intestines  from  the  anterior  abdominal  wall  towards  my 
fore-finger,  I  could  not  perceive  the  slightest  fluctuation  which 
could  induce  me  to  suspect  the  vicinity  of  the  terminal  end  of 
the  rectum.  Little  was  discovered  by  auscultation  of  the  per- 
in^eum,  during  percussion  of  the  walls  of  the  abdomen. 

"  Some  hours  later,  I  undertook  the  formation  of  a  perinaBal 
anus.  The  child  was  placed  on  its  back,  upon  the  table,  the 
legs  flexed  and  held  asunder  by  two  assistants,  while  a  third 
lield  the  small  silver  catheter  which  I  had  introduced  into  the 
bladder ;  then  I  introduced  a  silver  sound  into  the  opening  to 
the  depth  of  half  an  inch  and  placed  it  in  the  hand  of  an  assis- 
tant. Starting  at  this  point,  I  incised  the  skin  along  the  per- 
inseal  raphe,  to  within  three  lines  of  the  os  coccygis,  and  then 
divided  the  soft  tissues,  layer  by  layer.  An  artery  was  cut 
and  had  to  be  tied.  Presently  the  sound  escaped  from  the 
canal  which  could  not  again  be  found.  I  ceased  the  attempt 
to  introduce  the  sound  because  I  feared  I  would  injure  the 
bladder,  and  because  the  operation  seemed  to  fatigue  the  child  ; 
I  rather  sought  to  penetrate  the  pelvic  cavity  as  soon  as  pos- 
sible, and  whilst  an  assistant  wnth  the  hand  pressed  upon  the 
abdomen  of  the  child,  pushed  the  intestines  downward  to- 
wards the  pelvis,  with  my  finger  which  was  introduced  to  the 
depth  of  two  inches,  I  discovered  a  moderately  soft  body  situ- 
ated between  the  bladder  and  the  smooth  promontory,  its  an- 
terior portion  having  a  round  form,  and  adhering  to  the  pos- 
terior wall  of  the  bladder,  whilst  its  posterior  fiice  was  consid- 
erably extended  along  the  promontory.  By  the  touch  it  could 
be  slightly  brought  down,  and  this  made  me  suppose  that  it 
was  the  intestine  filled  with  solid  fk'cal  matter.  I  seized  it  by 
its  inferior   wall  with    artery   forceps,  and  brought   it  down 


THE    P^FTir    SrKCIKS    OF    MAI,K(MiMATI()N.  215 

C'fii'ofully,  whilst  with  tlie  end  oi'  my  fini,^cr,  T  (lestroyc'd  all 
the  luliiesions  uttachin^-  it  to  the  nei^h])i»riiii^  parts.  fii  tVinit 
I  could  not  altogether  succeed  ill  doin;^  this ;  ])ut  elsewiiere  I 
succeeded  so  completely  that  I  was  able  (<•  hrin*^  duwn  the 
])osterior  portion  into  the  ])erina'al  wound.  Contii-iued  in  niv 
suj)position  that  it  was  a  ])art  of  the  dilated  rectum,  1  seized  it 
tirndy  with  a  pair  of  forceps  and  a  crochet,  and  between  the 
two  instruments  I  made  an  incision  longitudiiuilly,  from  fiont 
to  rear,  about  nine  lines  in  len<i;th.  There  immediately  ])assed, 
by  the  increasing  efforts  of  the  child,  some  yellowish  brown 
matter,  the  evacuation  of  which  I  aided  with  a  spatula.  Yery 
shortly,  liquid  faecal  matter  passed,  of  a  green  color  and  acid 
odor.  I  then  cleansed  the  wound  with  injections  of  cold 
water.  I  divided  the  anterior  wall  of  the  canal,  as  far  as  I 
could  recognize  it,  and  then  nnited  the  edges  of  the  intestine 
with  the  lips  of  the  perinieal  wound  by  frequent  points  of  su- 
ture ;  then  I  nnited  the  edges  of  the  wound  in  front  and  rear 
of  the  anterior  and  posterior  angles,  by  means  of  suture,  and 
likewise  between  the  ans-les  of  the  intestinal  wound  and  those 
of  the  perinseal  w^ound.  The  most  anterior  suture  of  the  per- 
inaium  was  placed  in  such  a  manner  that  it  travei-sed  the 
mouth  of  the  canal.  I  prescribed  ap[)lications  of  cold  water 
to  the  perinaeum,  and  frequent  lotions  to  the  wound.  During 
tlie  night  the  child  slept  tranquilly,  but  the  next  day  it  uttered 
frequent  groans,  and  drew  up  its  legs  as  if  suffering  from  pain 
in  the  abdomen.  It  took  the  breast  but  seldom,  but  drank 
cold  water  with  avidity ;  respiration  was  accelerated,  and  the 
pulsations  of  the  heart  were  unusually  frequent.  The  lips  of 
the  wound  as  well  as  the  surrounding  parts  were  red  and 
somewliat  swollen  ;  yellow  liquid  fajcal  matter  of  very  acid 
odor,  was  evacuated  in  small  quantities  every  five  or  ten  min- 
utes through  the  newly  formed  anus.  I  prescribed  rhubarb 
and  syrup  of  saffron,  and  caused  warm  poultices  to  be  placed 
on  the  abdomen,  after  a  restless  night ;  the  next  morning, 
however,  the  child  was  better.  The  redness  and  swelling  of 
the  edges  of  the  wound  were  lessened,  and  they  seemed  thor- 
oughly united,  except  at  the  anterior  angle.  The  condition 
of  the  child  improved  daily  ;  suppuration  continued  in  the 
vicinity  of  the  fistulous  opening,  without,  however,  presenting 
any  mixture  with  faecal  matter.  Evacuations  occurred  only 
every  hour,  or  half  hour,  and  the  faeces  were  yellow  in  color 
and  of  the  consistence  of  pap. 

"  The  sixth  day  after  the  (Operation,  the  anus  took  an  oval 
form  ;  at  the  commencement  of  the  excretion  I  observed  dilat- 
ing motions  of  the  perinteum,  and  at  the  close  the  contraction 
of  the  anus  was  made  manifest  by  the  gathering  up  of  the  su- 


216  THE    FIFTH    SPECIES    OF   MALFORMATION. 

lure.  Some  of  the  needle  punctures  opened  into  each  other, 
and  discharged  a  shght  quantity  of  pus  ;  for  this  reason  I  took 
away  the  points  of  suture  in  question,  and  the  others,  two  days 
after.  The  union  of  the  edges  of  the  wound,  was  eveiTwliere 
complete. 

"  The  needle  punctures  which  had  been  open  were  now 
closed,  as  was  also  the  anterior  angle,  still  suppurating,  near 
the  scrotum.  On  the  fourteentli  day  after  the  operation,  tlie 
cure  was  complete,  tlie  jaundiced  discoloration  had  disap- 
peared, and  the  child  prospered  in  a  remarkable  manner. 
From  this  time  it  had  three  or  four  healthy  stools,  during  the 
twenty-four  hours  ;  the  appetite  was  good,*so  that  besides  the 
breast,  the  child  took  other  food,  and  none  of  the  preceding 
morbid  phenomena  reappeared. 

"  When  in  the  month  of  December,  1852,  I  again  saw  the 
child,  it  M'as  suffering  from  dentition,  and  often  carried  its 
hands  to  its  mouth  ;  the  gums  were  swollen  and  sensitive  to 
the  middle  of  the  lower  alveolar  edges.  The  child  wasted 
rapidly,  it  cried  out  all  night  long  and  began  to  cough.  On 
the  twenty-third  of  Decemljer,  I  found  in  the  upper  lobe  of 
the  left  lung,  and  in  the  upper  and  middle  lobes  of  the  right 
side,  a  rough  vesicular  murmur,  respiration  was  obscure,  as 
also  was  the  sound  produced  by  percussion.  Nevertheless 
the  child  breathed  a  little,  but  with  dithculty,  and  presented 
a  bluish  color  of  tlie  face.  The  pneumonia  resisted  treatment 
and  terminated  fatally  on  the  tAventy -fifth  of  December,  1852. 

"  The  autopsy  performed  the  next  day,  gave  the  following 
results.^In  the  cavity  of  the  cranium,  there  Avas  nothing  re- 
markable ;  in  the  large  bronchia,  a  catarrhal  secretion,  but  the 
mucous  membrane  was  not  red.  The  posterior  and  lower 
portion  of  the  inferior  right  lobe  was  tilled  with  blood  ;  the 
middle  portion,  and  the  lateral  portions  at  their  top  on  l;)eing 
cut  allowed  a  large  quantity  of  sanguinolent  and  frothy  serum 
to  escape,  and  the  bronchia  contained  a  viscid  catarrhal  i)ro- 
duct.  No  portion  was  found  to  contain  air.  Tlie  left  inferior 
lobe  was  studded  with  apoplectic  kernels,  from  the  size  of  a 
lintel  seed  to  that  of  a  pea,  and  near  them  the  pulmonary  tis- 
sue was  filled  with  blood,  partly  extravasated,  partly  fluid 
which  the  latter  especially,  was  easily  expressed.  In  these 
places  and  around  them,  the  pulmonary  tissues  contained  no 
air,  and  upon  pressure  gave  out  a  stringy  serous  exudation. 
In  the  pulmonary  vessels,  comprising  the  bronchial  tubes,  as 
far  as  I  could  follow  them,  I  found  no  blood  nor  any  other 
morbid  matter.  The  right  side  of  the  heart  was  filled  with 
black  liquid  blood,  and  at  the  left  posterior  wall  of  the  ventri- 
cle there  was  found  only  a  soft  fibrous  cord,  passing  into  the 


THE   FII'Tir    SPECIES   OF   MALFORMATION.  217 

I mlinonary  arteries;  the  left  sale  of  the  licjirt  coiitnincil  no 
l)h)od ;  the  f(i3tal  conduits  were  closed.  In  tlic  ulxloniinal 
cavity,  as  soon  as  tlu^  oincntuni,  luucli  cniaciatod,  had  lici-n 
raised  up,  a  dilatation,  tilled  with  i>;as,  and  conipi-jsini;  the 
eiul  of  the  ileum,  and  tlie  ui)i)er  j)art  of  the  descending;'  colon, 
jutted  out.  The  rectum  appeared  very  slutrt,  and  of  unecpuil 
size,  the  luirrowest  portions,  however,  were  of  normal  diani- 
e'er.  Ahout  one  inch  above  the  anus  there  proceeded  IVom 
the  anterior  wall  of  the  rectum,  a  cord,  the  size  of  a  larg-c 
knittinsj:;  needle,  directed  towards  the  vesical  triau<j:;lc,  and  at- 
tached to  the  bottom  of  the  bladdei*  by  cellular  tissue.  Thus 
fixed  and  becoming-,  smaller  and  smaller,  it  at  last  bent  its 
way  to  the  middle  surface  of  the  prostate,  towards  the  bulb 
of  the  urethra,  and  having  reached  its  posterior  wall,  was  lost 
beneath  the  fistulous  opening.  It  was  entirely  filled  up, 
and  it  was  only  at  its  ui)per  aiul  larger  portion,  that  the  exis- 
tence of  a  canal  could  be  perceived,  which  had,  hoNvever,  no 
longer  any  communication  with  the  cavity  of  the  rectum.  The 
interior  of  the  canal  no  longer  presented  the  appearance  of 
mucous  membrane.  W'here  the  cord  left  the  rectum  the  lat- 
ter presented  on  its  internal  surface  a  depression  of  a  medul- 
lary nature.  The  large  intestine  contained  a  yellow  ftecal 
nuitter,  liquid  and  semi-fluid;  the  mucous  membrane  was 
healthy  throughout.  The  artificial  anus  could  not  be  distin- 
guished from  a  normal  anus.  At  its  upper  portion  the  circu- 
lar fibres  of  the  rectum  were  so  strongl y  developed,  that  they 
represented  a  real  internal  sphincter.  The  cicatrized  needle 
marks  were  clearly  recognized.  The  liver  was  very  laro-e,  of 
a  nutmeg  shape  and  poor  in  blood.  The  biliary  ducts  were 
flexible,  the  gall  bladder  was  full  of  yellowish  brow^ii  bile  ; 
the  mucous  membrane  healthy.  Several  of  the  mesenteric 
glands  were  much  swollen  and  not  free  from  tubercles.  Be- 
sides this  the  abdominal  cavity  presented  nothing  remarkable. 
The  muscles  of  the  perineeum  did  not  seem  more  feebly  de- 
veloped than  usual." — {Recherches  Cliniques  et  Critiques  sur 
V Anus  Artijiciel.  In  Archives  Generales  de  Medicine  de 
Paris.     Jidllet.,  1857.     p.  oL) 

Case  CXYIII. — M.  Olinet  relates  the  case  of  a  female 
child  in  whom  the  rectum  opened  within  two  lines  of  the 
vulva,  the  rectum  being  prolonged  to  this  point  by  means  of 
a  canal.  Through  this  abnormal  anus  the  meconium  was  dis- 
chai-ged.  {,Tournal  Universel  des  Sciences Medicales.  Paris: 
Fevrier,  1820.) 

Case  CXIX. — Burns  thus  describes  the  case  of  a  female 


218  THE    FIFTH    SPKCIKS    OF   MALFORMATION. 

child  liaving  an  imperforate  anus,  accompanied  with  an  ab- 
normal anas: 

'•The  rectnm,  instead  of  terminating  at  the  usual  place, 
perforated  the  posterior  -wall  of  the  vagina;  then  occupying 
the  canal  of  the  vagina,  it  passed  through  the  vulva,  and  pro- 
jected about  an  inch  beyond  the  labia  pudendi,  bearing  a 
distinct  resemblance  to  an  imperfectlj'-  formed  penis.  It  was 
of  considerable  size,  possessing  a  writhing  motion,  and  freely 
discharged  meconium  by  an  orifice  at  its  apex."  {Edinburgh 
Medical  and  tSurgical  Journal^  Vol.  I.,  2^-  137.) 

Case  CXX. — M.  Yelpeau  says  that  M.  Brachet  published 
the  case  of  a  little  girl  who  had  an  abnormal  anus  situated  at 
the  fourchette  ^  the  normal  anus  was  imperforate.  {MoWs 
Velpeau,  Vol.  TIL,  p.  1087.     JVew  Tori:  1847.) 

Case  CXXI. — The  following  case  of  imperforate  anus,  with 
an  abnormal  opening  of  the  rectum  in  the  posterior  part  of 
the  vulva,  is  reported  by  M.  Caussade.  The  operation  in  this 
case  was  followed  by  com|)lete  success: 

"The  subject  of  this  case  was  a  female  infant  who,  when 
two  months  of  age,  was  in  an  almost  dying  condition,  taken 
to  M.  Caussade.  This  infant  vomited  fcecal  matters  ;  had  hic- 
cup ;  the  pulse  was  small,  contracted;  the  face  livid,  and 
covered  with  sweat  ;  the  voice  almost  extinct ;  and  the  abdo- 
men much  distended.  She  had  been  placed  out  to  nurse  im- 
mediately after  her  birth  ;  her  clouts  were  observed  to  be  wet 
and  slightly  soiled,  but  the  nurse  never  observed  any  alvine 
evacuation  as  in  other  children.  As  the  little  one  was,  how- 
ever, in  gopd  health,  and  even  grew  fat,  the  nurse  continued 
to  suckle  her  without  seeking  the  cause  of  the  absence  of 
alvine  evacuations.  On  examining  the  infant,  M.  C.  found 
that  there  was  no  anus,  or  trace  of  one.  She  passed  through 
a  capillary  opening  at  the  posterior  part  of  the  vulva,  very 
iiear  to  the  hymen,  a  thick  and  yellowish  fluid,  which,  M'hen 
the  intant  cried  and  struggled,  spouted  out  as  if  discharged 
from  the  spent  of  a  small  syringe.  During  the  straining  of 
tlie  infant,  a  tumor  projected  in  the  perina^um,  and  in  a  part 
of  the  breech.  To  relieve  tlie  perforation,  M.  Caussade  made 
an  incision  three  or  four  lines  in  depth  in  the  place  which  the 
anus  ought  to  have  occupied.  He  found  at  the  bottom  of  the 
incision  a  mass  of  hard  and  yellow  faical  matters.  It  was 
necessary  to  break  them  up,  and  they  were  removed  by 
means  of  a  scoop.  Several  injections  were  administered, 
which  brought  away  a  large  quantity  of  yellow  liquid  matter. 
The  wound  was  kept  open  by  a  lint  tent.     The  next  day  the 


TIIK    Finn    Sl'i:CIK8    OF   MALFORMATION.  219 

fecal  matters  were  readily  (Kscliartiicjd,  ;ill  the  unpleasant 
symi)tonis  ceased,  and  the  health  of  the  little  patient  was  re- 
stored."    {Gazette  des  Il6pitaux  de  Paris^  Mars  29,  1S34.) 

Case  CXXII. — George  Hay  ward,  M.  D.,  of  Boston,  Snrgcon 
to  the  Massachusetts  General  lIos{)ital,  reports  the  fol lowing 
interesting  case  of  imperforate  anus,  tlie  rectum  terminating 
in  the  labia  pudcndi  by  a  small  abnoi-nial  opening,  which 
performed  the  functions  of  an  anus.  The  operation  in  this 
case  was  attended  with  complete  success. 

"  About  eighteen  months  since,  I  was  desired  to  examine  a 
female  infant,  three  or  four  days  old,  in  consequence  of  a  mal- 
formation about  the  anus.  On  inspection  no  external  opening 
of  the  bowel  could  be  discovered  ;  but  in  separating  tlie  labia, 
it  was  found  that  the  urethra  and  vagina  were  perfect,  and  at 
two  or  three  lines  behind  the  vagina,  there  was  a  small  ori- 
tice,  sufficient  to  admit  the  large  end  of  a  prolje,  through 
which  the  faeces  were  discharged. 

"The  child  did  not  seem  to  suffer  at  all,  and  I  heard  noth- 
ing of  it  for  more  than  a  year,  though  I  visited  frequently  the 
famil}'  to  which  it  belonged.  A  few  days  after  it  was 
weaned,  which  was  in  January  last,  I  was  called  to  visit  it, 
and  was  told,  that  since  the  change  in  its  diet,  it  had  appa- 
rently suflered  very  much  in  its  eltbrts  to  discharge  the  con- 
tents of  its  bowels.  These  eftorts  were  violent,  almost  con- 
stant when  tlie  child  was  awake,  and  afibrded  scarcely  any 
relief.  Since  it  had  ceased  nursing,  it  liad  become  emaciated 
and  very  feeble,  and  had  but  little  continuous  or  quiet  sleep, 

"  After  it  was  weaned,  its  diet  consisted  of  milk  and  barley 
flour,  and  the  fseces,  no  doubt  in  consequence  of  the  change 
in  the  food,  had  become  of  much  greater  consistence.  The 
contents  of  the  bowels  were  forced  out  by  violent  straining  in 
small  pieces,  quite  solid,  about  the  size  of  a  duck  shot. 

"  On  examining  the  parts,  I  found  that  the  outlet  of  the 
bowel  w^as  but  little,  if  any  larger  than  when  I  saw  it  before, 
and  the  large  end  of  a  probe  did  not  pass  very  readily  into  it. 
The  moment,  however,  that  it  was  introduced,  strong  convul- 
sive efibrts  followed,  and  it  was  evident  that  there  was  a 
great  accumulation  of  ftecal  matter  in  the  intestine,  lying  in 
ilie  hollow  of  the  sacrum. 

"As  it  was  apparent  that  the  child  would  not  live  long  in 
this  way,  I  suggested  the  expediency  of  attempting  to  relieve 
it  by  an  operation  ;  though  i  confess  that  I  was  not  very  san- 
guine as  to  its  success,  nor  did  I  give  a  very  favorable  prog- 
nosis to  the  parents  as  to  the  result.     They  consented,  how- 


220  THE    FIFTH    SPECIES    OF   MALFORMATION. 

ever,  and  on  the  following  day.  Jan.  26tli,  1853,  I  performed 
it  in  the  following  way  : 

"  The  child,  having  been  rendered  insensible  by  the  inhal- 
ation of  rectified  snlplmric  ether,  was  laid  on  a  table.  A 
"iirector  of  the  smallest  size  was  introduced,  thongh  with  dif- 
ficulty, about  an  inch  into  the  bowel,  with  the  groove  towards 
the  sacrum.  With  a  very  narrow  knife  passed  into  the 
groove,  I  enlai'ged  the  external  opening  of  the  bowel  suffi- 
ciently to  admit  my  fore-linger,  and  continued  the  incision 
upwards  nearly  to  the  end  of  the  director;  I  then  found  that 
I  could  pass  my  finger  readily  into  the  bowel,  which  aj^peared 
to  be  of  the  usual  size,  till  within  about  an  inch  of  its  outlet, 
where  it  had  been  contracted  into  a  small  canal,  certain!  v  not 
one  fourth  as  large  as  the  bowel  above. 

"  I  did  not  consider  it  necessary  to  carry  the  incision  any 
farther ;  nor  did  I  deem  it  safe ;  partly  from  the  fear  of  hem- 
orrhage, and  in  part  from  an  apprehension  that  if  I  did  so  I 
sliould  destroy  the  retentive  power  of  the  bowel,  as  sometimes 
happens  from  an  operation  for  fistula  in  ano,  where  it  has 
been  found  necessary  to  divide  the  parts  high  up. 

"  Lint  was  applied  to  the  edges  of  the  wound,  and  a  cloth 
wet  in  cold  water  laid  over  it.  There  was  no  bleeding,  ex-' 
cept  a  slight  oue  at  the  time ;  the  child  was  evidently  re- 
lieved, though  the  fiiecal  matter  was  not  discharged  till  castor 
oil  was  administered  on  the  following  day. 

"In  two  days  after  the  operation  I  introduced  a  moderate- 
sized  rectum  bougie,  of  a  diameter  as  large  as  that  of  the 
bowel,  and  this  has  been  done  daily  to  the  present  time.  In 
a  very  few  days  the  wound  healed,  and  the  child  has  appa- 
rently sufi'ered  no  inconvenience  since.  It  has  regular  evac- 
uations of  a  proper  consistence  without  the  use  of  medicine. 
It  has  the  entire  control  of  the  bowel,  and  has  regained  its 
health.  It  is  now  vigorous  and  active  as  female  children  of 
that  age  nsuallv  are. 

"  I  examined  the  parts  very  recently,  four  months  after  the 
operation.  The  anus  can  now  be  seen  without  separating  the 
labia ;  but  the  perina?um  is  covered  with  the  same  delicate 
mucous  membrane  that  lines  the  vagina.  Whether  this  will 
ever  be  productive  of  inconvenience,  it  is  not  perhaps  easy  to 
say  ;  it  is  probable  that  this  membrane  niay  lose  some  of  its 
sensibility,  but  there  is  no  reason  to  suppose,  that  it  will 
ac(piire  the  properties  of  the  ordinary  covering  of  the  body. 

"  This  case  must  be  regarded  as  a  favorable  one  of  mal- 
formation of  this  kind.  In  some  that  have  been  described, 
the  <»pening  into  the  vagina  was  as  large  as  the  diameter  of 
the  bowel,  and  there  was  no  sphincter ;  while  here  the  lower 


THE    FIFTH   SI'KUIKS    OF    MA[,F(»K.\r  Air<  »N'.  2:^1 

pjirf  of  the  rectum  was  contmetiMl  into  a  narrow  canal,  fiir- 
iiislu'd  with  lunscuhir  power  sulHcieiit  to  prevnit  the  invohiii- 
tary  (lisehari;-e  of  the  fa'ces.  WJiere  there  is  no  provision  of 
this  kind,  tlie  nialfonuatiou  must  of  course  be  oho  of  the  most 
(lisgustin<j^  character."  {The  Virginia  Mcdiml  and  Sanjical 
Jiiiu'ital,    Vol.  I., p.  ^iy'^.     Richmond:  1S53.) 

Cask  CXXIII. — Professor  Nagel  reUites  the  followiui!^  case 
of  imperforate  anus,  being  the  second,  though  of  a  ditferciit 
species,  M'hich  he  communicated  to  the  "  ^Society  of  Practical 
Meilicinc  of  BerlinP 

''  Tills  second  case  of  Dr.  Nagel's  occurred  in  a  female  child 
six  months  old.  There  was  imperforate  anus  and  an  abnormal 
opening  of  the  rectum  at  the  entrance  of  the  vagina,  at  the 
point  ol  the  lower  commissure;  a  small  tono-ue  with  its  edire 
l):-esented  to  the  front  completely  closed  this  opening.  A 
sound  could  not  only  be  introduced  with  ease  into  the  rec- 
tum, but  could  also  be  pushed  against  the  perina^um,  and  IV-lt 
in  front.  The  child  although  doing  well,  often  sutfered  with 
colic  and  tenesmus,  especially  when  fruit-stones,  green  goose- 
berries covered  wath  their  skin,  or  similar  bodies  were  re- 
tained in  the  narrow  anal  aperture,  or  when  impacted  fieces 
were  collected  in  the  false  passage  behind  the  orifice.  Consti- 
pation became  more  and  more  frequent,  and  the  means 
hitherto  employed  to  obtain  liquid  stools  continued  ineffectual. 
Nagel  then  decided  upon  an  operation,  which  he  performed 
by  the  process  of  Dieftenbach.  By  means  of  a  hollow  bent 
sound  he  easily  formed  the  new  anus  ;  the  muc<ius  coating  of 
the  open  intestine  was  joined  to  the  skin.  In  the  part  of  the 
rectum  situated  in  front  of  this  new  anus,  that  is  to  say,  in 
the  canal  which  opened  at  the  point  of  the  posterior  commis- 
sure of  the  vagina,  Nagel  introduced,  eight  days  after,  a  red- 
hot  iron,  but  without  succeeding  in  obliterating  it,  A  small 
([uantity  of  fsecal  matter  still  continued  to  pass  therefrom. 
Nagel  feared  to  divide  the  cutaneous  bridge  which  separated 
the  artificial  from  the  abnormal  anus,  considering  the  section 
of  the  circular  fibres  of  the  sphincter  going  to  the  vagina,  and 
the  incontinence  of  ffecal  matter,  consequent  upon  the  section 
of  the  canal,  as  a  still  greater  inconvenience."  [Recherches 
Clinques  et  Critiques  sur  IJAnus  Artijiciel.  Par  le  Dr. 
Ilerinann  Friedherg.  Archives  Genercdes  de  Medicine  de 
Paris.     Jfai,  1857.    p.  581.) 

Case  CXXIY. — ^Tlie  following  case  was  communicated  to 
J.  C.  Lettsom,  M.  D.,  by  Mr.  T.  Mantell,  of  Dover,  England, 
in  a  letter  dated,  Dover,  May  25th,  1789 : 


222  THE   FIFTH   SPECIES   OF  MALFOKMATION. 

"  JVIrs.  S was  delivered  of  a  female  child  in  September, 

1786.  A  few  days  after  I  was  informed,  that  no  proper 
evacuation  of  meconium  had  taken  place,  and  that  some  small 
quantity  of  faeces  had  come  away  with  the  urine.  On  exam- 
ination I  found  that  a  malformation  was  the  cause,  there  not 
being  any  anus,  or  the  least  appearance  of  one.  The  infant, 
in  other  respects,  was  well  formed  :  the  vagina  was  perfect, 
and  the  water  passed  naturally  by  the  urethra ;  the  health  of 
the  child  was  bad  ;  she  appeared  generally  in  great  pain,  was 
very  costive,  and,  by  violent  forcings,  a  little  quantity  of  hard 
fteces  were  driven  out,  in  the  form  of  small  spiral  strings,  per 
vaginam. 

"  On  acquainting  the  parents  with  the  danger  of  the  case, 
and  proposing,  as  the  only  relief,  to  make  an  incision  through 
to  the  intestine,  and  by  that  means  endeavor  to  obtain  a  natu- 
ral mode  of  evacuation,  they  requested  me  to  do  whatever  I 
thought  proper. 

"  As  I  had  no  direction  by  an  impulse  of  the  foeces  against 
the  skiu,  I  chose  the  usual  natural  distance  from  the  vagina, 
and  made  a  deep  but  small  incision,  and,  by  passing  a  curved 
probe  by  the  vagina,  through  the  aperture  into  the  rectum,  I 
soon  felt  it,  and  was  guided  by  that  to  proceed  till  the  dis- 
charge of  fieces  came  plentifully  through  the  new  aperture  ; 
the  haemorrhage  was  not  great,  and  tlie  child  was  imme- 
diately relieved.  To  prevent  constipation,  and  avoid  pain  by 
the  expulsion  of  hard  faeces,  I  gave  laxative  medicines,  and 
my  young  patient  felt  little  inconvenience,  though  there  still 
continued  some  small  discharge,  as  before,  per  vaginam.  At 
the  month's  end  it  removed  with  its  mother  to  town,  and  I 
saw  no  more  of  them  till  the  spring  of  1788,  when  I  was 
informed  by  Mrs.  S that  the  child  had  been  very  un- 
healthy, that  it  had  sutfered  from  many  disorders,  and  was 
still  troubled  (particularly  when  costive)  in  voiding  the  faeces  ; 
and  that  the  orifice  I  had  formerly  made  had  been  so  much 
closed  as  to  render  it  necessary  for  a  surgeon  to  dilate  it,  and 
yet  it  was  now  again  very  confined,  which  made  such  a  con- 
stant use  of  purging  medicines  necessary,  as  to  debilitate  the 
constitution  of  the  emaciated  little  subject. 

"  I  had  formerly  been  afraid  of  making  the  aperture  large, 
lest,  if  I  did,  the  powers  of  retention  would  be  lost ;  but  there 
now  being  a  kind  of  stricture  at  the  part,  induced  me  to  think 
the  levatores  and  sphincter  muscles  were  not  deficient ;  and 
that  no  mischief  would  ensue,  if  I  enlarged  the  orifice. 
Accordingly  I  made  a  large  incision,  and  afte*'  this  no  further 
difiiculties  arose,  the  child  became  healthy,  and  I  have  the 
satisfaction  of  finding,  near  a  year  since  the  last  operation, 


TIIK    FIFTH    SPECIES    OF    MAI.lOIiMATIt  iN.  223 

tliat  slio  contiiinos  perfectly  well."  (M'  ntoirs  <>f  the  Mxlical 
fSocliii/  of  London.,  Vol.  I J  I..,  Art.  XIX..,  v.  389.  London  : 
1792.) 

Cask  CXXV. — The  late  and  lamented  Dr.  Miitter,  lorinerlv 
the  able  and  distini»;uishe<l  Professor  of  Surgery  in  tlie  Jefler- 
sou  Medical  Oolle<^e  of  Philadel])hia,  conuuunicated  to  Dr. 
Meigs  the  following  interesting  case,  in  a  letter  dated  October 
4th,  1844  : 

"  In  compliance  with  your  rerpiest,  I  send  a  Ijrief  notice  of 
the  case  of  Imperforate  Anus,  of  which  you  s])oke  the  other 
day.  About  the  last  of  April,  1844,  I  was  requested  by  Dr. 
Jewell  to  visit,  in  consultation,  the  female  infant  (two  weeks 
old)  of  one  of  his  patients.  On  examination,  the  following 
condition  of  things  was  observed  :  The  rectum  terminated  in 
a  cul-de  sac,  which  extended  to  within  three  or  four  lines  of 
the  natural  position  of  the  orifice  of  the  gut,  which  spot  was 
occupied  by  dense  cellular  tissue  and  common  integument, 
and  no  trace  of  the  anal  opening  could  be  distinguished.  We 
were  told  that  the  child  was  in  the  habit  of  passing  its  faeces 
through  the  va'/ina,  and  that  each  evacuation  was  attended 
with  violent  efforts,  while  the  fiscal  matter  was  moulded  into 
snuill  threads.  Separating  the  labia,  an  opening  about  the  size 
of  a  small  duck-shot  was  discovered  just  withhi  the  fourchette, 
and  above  it,  a  well-formed  hymen.  Through  this  opening  a 
probe  was  readily  passed  into  the  rectum,  and  also  through 
the  hymen  into  the  vagiiui,  and  both  canals  appeared  perfectly 
normal,  with  the  exception,  of  course,  of  the  defect  already 
described.  The  indication  was  obvious,  and  I  at  once  pro- 
posed the  following  operation.  With  the  view  of  establishing 
a  proper  channel  for  the  faeces,  and,  at  the  same  time,  dispose 
the  orifice  between  the  rectum  and  vagina  to  contract  and 
thus  heal.  Passing  a  small  grooved  director  from  the  vagina 
into  the  rectum,  1  forced  out  the  tissues  forming  its  lower 
extremity,  and  then  thrust  a  trocar  down  to  the  director  and 
directly  tlirough  the  spot  usually  occupied  by  the  natural  ori- 
fice of  the  intestine.  Withdrawing  both  instruments,  I  next, 
with  a  probe-pointed  bistoury,  enlarged  the  opening  made  by 
the  trocar,  and  as  soon  as  this  was  accomplished,  the  child 
passed  an  immense  quantity  of  ftecal  matter,  apparently  with 
much  relief.  A  sponge-tent  was  then  introduced  into  the  rec- 
tum, and  the  nurse  instructed  as  to  its  objects  and  use. 

"  Being  on  the  eve  of  sailing  for  Europe,  I  did  not  see  the 
child  again,  but  suggested  the  continued  use  of  the  sponge- 
tent,  until  the  opening  made  had  lost  all  disposition  to 
contraction ;  and,  after  this,  if  the  orifice  in  the  vagina  did 


224  THE    FIFTH    SPECIES    OF   MALFORMATION. 

not  heal  of  its  own  accord,  in  consequence  of  the  natural 
channel  for  the  fasces  being  established,  that  it  should  be 
touched  occasionally  with  tlie  argent  nitrat. 

"  I  did  not  deem  this  a  case  in  which  the  operation 
of  Aniussat  was  advisable,  nor  Avas  it  one  that  indicated 
(ituu.noii  of  the  tissues  occupying  the  position  of  the  anal 
oritice,  nor  could  any  operation  upon  the  fistulous  open- 
ing between  the  rectum  and  vagina  be  with  propriety  pro- 
posed. I  preferred  the  trocar  to  a  sharp-pointed  hisfoury^  for 
performing  the  operation,  for  the  simple  reason  that  wounds 
nuitle  with  the  former  instrument  are  much  less  prone  to  heal 
by  the  first  intention  than  when  the  latter  is  em^^loyed ; 
and  as  it  was  one  object,  of  course,  to  prevent  the  close  of  the 
gut  again,  an  event  by  no  means  uncommon,  when  a  simple 
conical  incision  is  made  with  a  bistoury,  I  adopted  the  plan 
of  operating  described.  I  have  not  seen  the  child  since 
my  return,  but  understand  from  Dr.  Jewell  that  there  is  some 
contraction  of  the  orifice,  and  that,  in  all  prol)al)ility,  it  will 
be  necessary  again  to  divide  its  margins."'  {^A  Treatise  on  tlm 
Diseases  and  Special  Hygiene  of  Females.  By  Colomhat  De 
Vlsere.  Translated  from  the  French.,  hy  Charles  D.  Meigs., 
M.  D.   p.  116.     Philadelphia  :  1845.) 


CHA^r^TER   VII. 

THE    SIXTH    SPECKS   OF  MALFORMATION. 
SECTION      I. 

DESCRIPTION. 

1.  This  species  is  recognized  by  the  rectum  terminating  by 
an  abnormal  anus,  either  in  the  bladder,  the  urethra,  the 
vagina,  the  uterus,  or  in  a  cloaca  in  the  perinseum  with 
the  urethra  and  the  vagina.  There  is  generally  neither 
a  natural  anus  nor  the  sign  of  one  present ;  yet  sometimes, 
though  rarely,  a  small  contracted  orifice  indeed  exists,  at  the 
natural  situation,  simulating  the  normal  anus,  which  permits 
the  introduction  of  the  end  of  a  small  probe  for  a  few  lines. 
Mr.  Cooke  and  Mr.  Lucas  have  each  seen  and  reported  a  case 
of  this  description.     [  Vide  Oases  CXXXYI—CXG  F/.] 

2.  This  preternatural  alliance  of  the  digestive,  the  urinal 
and  the  generative  systems,  which  is  analogous  to  the  normal 
formation  of  some  animals,  comprises  that  division  of  the  con- 
genital malformations  of  the  anus  and  the  rectum  which 
Meckel  very  appropriately  denominates — "  Cloaca  Congenital,'''' 
and  which  is  the   ^''Atresia  Ani  Vesicalis,    Urethralis  and 

Yaglnalis'''  of  Papendorf. 

3.  The  variety  of  this  species  of  congenital  vice  in  which 

the  rectum  opens  into  the  bladder,  is  much  more  common  in 

the  male  than  in  the  opposite  sex.     Tliere  are  indeed  but  few 

cases  of  the  latter  on  record,  and  even  those  few  are  by  no 

means  well  authenticated.    Tlie  celebrated  Morgagni  reports  a 

case  from  mere  hearsay.    [  Yide  Case  CXXIX.^ 
15 


226  THE   SIXTH   SPECIES   OF   MALFOKMATION. 

Aristotle  gives  the  singular  instance  of  a  cow  wliicli  pre- 
sented not  tlie  slio-htest  trace  of  an  anus  in  situ  naturali.  He 
sa3's,  in  this  case,  that  "Me  excretnentitious  jmHs  of  the  food, 
heing  attenuated.,  were  discharged  through  the  bladder^  {De 
Generatione  Animalium.    Lib.  IV.,  C.  4,  in  Jin,) 

4.  There  are  but  few  cases  on  record  of  the  variety  of  this 
species  of  malformation,  in  which  the  rectum  oj^ens  into  the 
female  urethra.  Licetus  and  Delesalle  report  each  a  case. 
[  Vide  Cases  CLI—GLIIL  ] 

5.  Some  of  the  instances  in  which  the  rectum  communi- 
cates with  the  bladder  in  the  male,  are  accompanied  with  an 
imperfect  development  of  the  penis,  especially  occlusion  of 
the  prepuce  and  urethra.  M.  Desgenettes  records  a  case  of 
this  charactei-.     [  Vide  Case  CXXXII?\ 

6.  The  rectum,  in  the  majority  of  instances,  instead  of  com- 
municating directly  with  the  bladder  by  simply  an  orilice, 
terminates  obliquely  in  this  viscus,  between  the  insertion  of 
the  ureters,  by  a  short  conical  canal,  the  vesical  orifice  of 
which  being  sometimes  so  small  in  diameter  as  scarcely  to 
admit  the  end  of  the  smallest  sized  probe.  This  narrow  con- 
ical duct  or  rectal  extremity,  the  base  of  which  corresponds 
to  the  superior  extremity  of  the  rectum,  or  inferior  extremity 
of  the  colon,  and  which  is  observed,  in  these  cases,  to  connect 
the  rectum  and  the  l>ladder,  is  said  by  Dr.  J.  B.  S.  Jackson, 
of  Boston,  to  resemble  very  much  the  ductus  arteriosus. 
{Recoi'ds  of  tlie  Boston  Society  for  Medical  Iinprovement, 

VoK  III.,  J)'  158.     Boston:  1859.) 

7.  The  rectum,  wlieu  it  terminates  in  the  urethra,  does  so 
by  a  narrow  conical  canal,  and  quite  small  orifice,  as  it  does 
in  the  bladder,  and  in  the  largest  number  of  instances  opens 
into  the  membranous  portion  of  the  urethra. 

8.  When  the  rectum  terminates  in  the  vagina  the  recto 
vaginal  orifice  is  generally  mucli  larger  than  when  it  opens 
into  the  urinary  passages.     In  some  few  instances,  however, 
it  terminates  by  a  canal  which  becomes  gradually  narrowed 


THE    SIXTH  STKOIES    OF   MALI-UlCMATloN.  227 

as  it  approaches  tlio  vagina,  luilil  it  is  quite  small.  The  va- 
ginal anus  will  nsiuilly  be  found  situated  htw  down  in  some 
part  of  tlie  posterior  or  lateral  parietes  of  the  vaginal  canal. 
[  Vide  Plate  IX,  Figure  1.] 

Papendorf  reports  a  case  in  which  the  rectum  terminated  at 
two  [)oints  in  the  vagina.  S.  F.  Ainsworth,  M.  D.,  of  our  own 
country,  records  a  similar  case.  [  Vide  Cases  CLXXXVl— 
CCIIL] 

9.  Physical  Signs — Diagnosis.  Should  the  abnormal  open- 
ing of  the  rectum  be  vesical,  its  existence  will  be  manifested 
by  the  thickness  of  the  urine,  and  by  its  greenish  appearance, 
which  it  acquires  from  being  blended  and  tinged  with  the 
meconium  previous  to  its  expulsion  from  the  bladder;  and 
by  its  passing  only  at  the  time  of  urinating.  These  evidences 
are  sufficient  to  show  that  the  abnormal  opening  is  entero- 
vesical,  but  they  are  not  sufficient  to  indicate  the  direction,  or 
the  precise  point  of  the  termination  of  the  rectum.  This  is 
often  quite  difficult,  if  not  impossible  to  determine.  When 
the  urine  is  so  much  mixed  with  the  meconium  as  to  become 
semi-fluid,  it  is  an  evidence  that  the  recto-vesical  opening  is 
large ;  when  on  the  contrary  it  merely  tinges  the  napkins,  it 
is  evident  that  the  abnormal  opening  is  small.  Besides  the 
passage  of  the  meconium  through  the  bladder  and  urethra, 
gas  is  also  often  expelled  through  the  same  medium. 

Should  the  abnormal  opening  of  the  rectum  be  urethral, 
the  meconium  will  often  escape  unmixed  wath  the  urine, 
either  constantly  in  small  quantities,  or  at  intervals,  or  a 
small  jet  will  always  precede  the  passage  of  the  urine.  The 
meconium  is  sometimes  also  forced  out  in  small  cylindrical  or 
spiral  bodies.  It  is  also  difficult  in  these  cases  to  determine 
at  what  point  the  rectal  opening  enters  the  urethra,  wliether 
at  a  short  distance  from  the  glans  penis,  or  deeper  down  near 
the  perinseum. 

10.  Prognosis.  The  prognosis  in  those  cases  in  which  the 
rectum  communicates  with  the  bladder  or  the  urethra  of  the 


228  THE    SIXTH    SPECIES    OF    MALFORMATION. 

male  is  always  very  unfavorable,  and  unless  such  cases  are 
relieved  by  prompt  surgical  measures,  as  a  general  rule,  they 
soon  end  in  death.  In  these  instances  the  great  danger  and 
difficulty  are  at  once  obvious,  when  we  take  into  considera- 
tion the  smallness  of  the  recto-vesical  opening  generally,  and 
the  length,  narrowness  and  flexure  of  the  male  urethra.  The 
extremely  delicate  and  highly  sensitive  mucous  lining  too,  of 
the  bladder  and  the  urethra,  is  not  capable  of  sustaining  for  a 
length  of  time,  without  imminent  danger  of  fatal  cystitis,  the 
immediate  contact  of  the  highly  irritating  stercoraceous  mat- 
ters ;  and  when  the  recto-vesical  orifice  is  so  small  that  noth- 
ing but  the  thinnest  portions  of  the  meconium  can  pass 
through  it,  the  great  danger  then  is  from  the  accumulation 
and  the  retention  of  the  excrementitious  matters.  Should  the 
child  even  under  these  unfavorable  circumstances  continue  to 
survive  for  several  months,  as  soon  as  the  fseces  increase  in 
quantity  and  acquire  a  certain  degree  of  consistence,  and  ac- 
cumulate, the  life  of  the  unfortunate  little  patient  could  no 
longer  be  sustained. 

11.  Much  the  same  difficulties  and  dangers  attend  those 
cases  in  which  the  rectum  terminates  in  the  male  urethra. 

It  was  declared  by  M.  Bertin,  many  years  ago,  that  this 
particular  malformation — that  is,  that  in  which  the  rectum 
opens  either  into  the  bladder  or  the  urethra  of  the  male — 
uniformly  resulted  in  death.  {Memoire  de  V Academic  des 
Sciences.  AfinSe  1Y71.  j:).  496.)  This  opinion  is  still  held  by  a 
number  of  surgeons  of  the  present  day,  but  it  is  not  altogether 
tenable,  for  it  will  be  seen  that  several  cases  have  been 
reported  in  which  life  has  been  prolonged  for  months  and 
even  for  years.  M.  Bravais  mentions  the  case  of  a  i)oj  four 
years  old.  [  Vide  Case  CZIL]  Flajani  reports  an  interesting 
case  of  a  child  four  months  old.  [Vide  Case  CZIV.]  M. 
PouUetier  saw  a  boy  three  years  old,  who  passed  all  his  fseces 
through  a  preternatural  opening  of  the  rectum  into  the  ure- 
thra.   [  Vide  Case  CL  Vin.~\     Professor  Gross,  of  Philadel- 


THE    BIXTII    SPECIK8    OF   MALKOltMATION.  229 

pliia,  luinies  two  cases.     One  a  very  reinarkaljlc  one.     [  Vide 

Case  aZ.] 

12.  The  prognosis  is  somewliat  more  favoraLle  wlicii  tlic 
rectnm  communicates  with  the  bUidikM-  or  tlio  urethra  of  the 
lemale,  in  consef|ueuce  of  the  shortness  and  the  straightness  of 
the  uretlira,  and  its  great  susceptibility  of  diUitation. 

13.  The  prognosis  is  much  more  favorable  when  the  rectum 
communicates  with  the  vagina  than  when  it  opens  into  the 
urinary  passages,  in  consequence  of  the  greater  amplitude  of 
the  recto-vaginal  aperture  generally  in  these  cases,  and  the 
width  and  the  straightness  of  the  vaginal  canal  which  tluis 
affords   an   ample  passage  for  the  easy  egress  of  the  ficcal 
dejections.     The  vaginal  anus  wdien  large,  as  is  usually  the 
case,  does  not  give  rise  to  fatal  results,  does  not  compromise 
the  life  of  the  patient,  neither  does  it  in  after  life  interfere 
with,  nor  prevent  the  functions  of  the  vagina  and  the  uterus. 
Several  instances  have  been  recorded  of  such  patients  having 
grown  up  to  womanhood,  and  even  of  having  been  capable  of 
becoming  pregnant  and  of  bearing  children,  without  any  very 
serious  impediment  to  life  or  inconvenience,  excej)t  the  very 
disgusting  nature  of  the  infirmity  itself.     M.  Fournier  cites 
the  case  of  a  woman  who  became  a  mother,  who  had  a  con- 
genital imperforate  anus  with  an  abnormal  opening  of  the 
rectum    in    the    vagina.     [Vide    Case    CXCIII.]      Kicord 
reports  the  singular  case  of  a  courtesan  twenty-two  years  of 
age,  who  presented  a  congenital  imperforation  of  the  anus 
with  an  abnormal  opening  of  the  rectum  in  the  vagina.     A 
similar   case   to   this    in    almost    every   respect,   is    related 
l)y  Switzer.     [Vide  Cases  CCI—CCII.]     Morgagni  records 
the  cas©  of  a  woman  who  from  birth  was  afflicted  with  this 
infirmity,    and   who   attained   the  extraordinary  age  of  one 
hundred  years.     [  Vide  Case  CZXXVII.] 

14.    Although  we  have  shown  that  the  unfortunate  subjects 

of  this  affliction  are   generally  in  no  immediate  danger  of 

death,  yet  the  imperfection  is  one  of  a  peculiarly  delicate 
9 


230  THE    SIXTH    SPECIES    OF   MALFORMATION. 

cluaracter,  and  one  that,  should  life  be  spared  and  prolonged, 
would  only  entail  miseiy  upon  the  unfortunate  victim  of  it. 
The  manner  in  which  such  a  malformation  would  operate 
upon  the  mind,  should  the  patient  thus  afflicted  arrive  at  the 
age  of  reflection,  can  well  be  imagined,  when  we  take  into 
consideration  the  disgusting  and  the  repulsive  nature  of  the 
deformity  itself. 

'  15.  All  the  cases  in  which  the  rectum  opened  into  the 
vagina  were  until  of  late  years  considered  liopelessly  incura- 
ble, and  even  many  surgeons  still  consider  them  so.  They  are 
the  opprobrium  medicoruTn.  Surgery,  however,  must  remedy 
this  repulsive  infirmity  hereafter,  and  thus  wipe  out  this  dis- 
grace. This  she  has  already  to  a  considerable  extent  accom- 
plished. 

16.  In  some  of  the  cases  under  consideration,  however,  the 
mucous  membrane  of  the  vagina  sooner  or  later  becomes 
excoriated,  indurated  and  fungated  from  the  neglect  of  clean- 
liness, and  abscesses  often  form  in  the  adjacent  cellular  tissue. 
Such  cases  generally,  are  deplorably  hopeless. 

17.  With  regard  to  the  prognosis  of  those  extremely  rare 
cases  in  which  the  rectum,  together  with  the  genito-urinary 
organs  terminates  in  a  cloaca  in  the  perinseum,  as  observed 
in  the  monotremata,  in  birds,  in  reptiles  and  in  many  fishes, 
it  is  useless  to  conjecture.  Such  cases  would  seem,  as  a  mat- 
ter of  course,  to  be  beyond  all  hope  of  remedy.  Only  one 
such  case  in  the  human  subject,  as  far  as  my  reading  extends, 
is  recorded,  and  that  one  was  observed  by  Saviard,  and  which 
I  have  presented  entire.     [  Vide  Case  CCIY.^ 

Martin  saw  a  malformation  of  this  nature  in  a  full-grown 
bitch.     {Annates  de  Societe  Natur.  tome  XII.) 

Hartmann  observed  a  lusus  of  this  character  in  a  heifer. 
{Miscellanea  curiosa  sive  ephem.  acad.  natur.  curiosor.  decur. 
II.  ann.  VII  et  VIII  p.  59.) 

18.  The  operation  for  the  establishment  of  an  artificial  anus 
in  the  perinseum  in  all  these  cases  in  which  there  is  an  outlet 


TIIK    SIXTH    KPECII2S    OF   MALFORMATION.  231 

for  tlie  mecoiiiimi,  gas  and  l-occs,  even  tlioiiol,  it  l.e-  Hiiall,  is 
much  more  favorable  than  if  \u>  outUi  whatever  existe(h  Tlie 
operation  can  therefore  be  always  iiiulertakeii  with  bli-on-a-r 
] lopes  of  success  in  these  instances. 


SECTION    II. 
THE  TREATMENT. 

1.  The  treatment  for  the  relief  of  that  variety  of  this  spe- 
cies of  congenital  malformation  in  which  the  rectum  termi- 
nates in  the  bladder  or  in  the  urethra,  is  by  no  means  void  of 
dithculty  and  danger,  and  not  well  calculated  to  inspire  the 
surgeon  with  confidence. 

2.  Tlie  indication  in  these  cases  is  to  establish  an  artificial 
aims  in  the  peringeum,  if  the  end  of  the  rectum  can  be  found, 
and  thus  open  a  new  route  for  the  free  exit  of  the  fsecal  mat- 
ters which  may  all  in  course  of  time  be  diverted  from  the 
abnormal  route,  and  in  this  way  enable  it  to  become  gradually 
obliterated. 

3.  Should  the  rectum  open  either  into  the  bladder,  or  into 
the  urethra,  and  the  child  be  threatened  with  speedy  death, 
the  surgeon  should  at  once  proceed  to  search  for  the  end  of 
the  rectum,  as  advised  in  cases  of  imperforation  of  the  anus 
and  rectum,  and  if  possible,  form  an  artificial  anus  in  the 
natural  situation,  capable  of  giving  free  egress  to  the  accumu- 
Lited  meconium,  excrement  and  gas.  Afterwards  the  newly- 
formed  passage  should  be  maintained  pervit)us  in  the  manner 
already  advised. 

4.  Although  this  operation  may  not  obviate  all  the  incon- 
veniences of  this  infiiTiiitv,  it  w^ill  nevertheless  at  once  relieve 
the  urgent  symptoms,  and  give  ample  time  to  put  into  requi- 
sition other  measures,  if  necessary.  Tlie  new  passage  may 
neither  altogether  prevent  the  fseces  from  following  the  other 


232  THE    SIXTH    SPECIES    OF   MALFOEMATION. 

route,  yet  it  will  certainly  divert  the  largest  portion  of  them 
and  in  this  way  very  materially  improve  the  condition  of  the 
unfortunate  little  sufferer,  and  enable  the  abnormal  j^assao-e 
and  orifice   finally  to   become   obliterated   when   the   fteces 
acquire  more  consistence  and  become  less  frequent. 

6.  M.  Amussat  advises  that  in  case  the  rectum  opens  into 
the  bladder  or  the  urethra,  that  only  the  posterior  wall  of  the 
rectum  should  be  drawn  down,  because  if  the  oj^ening  could 
not  be  closed,  an  extravasation  of  urine  might  ensue.  lie  re- 
ports an  interesting  case  upon  which  he  operated,  but  unfortu- 
nately without  success.  In  order  to  give  his  method  of 
operating  and  his  reflections  on  the  subject,  I  have  presented 
his  case  in  full,  translated  from  the  French.  [  Vide  Case 
CXLIV.] 

I  have  also  presented  two  highly  encouraging  cases,  success- 
fully operated  on  by  two  of  our  own  talented  countrymen, 
Drs.  Buckingham  and  Gilman,  These  two  cases  reflect  great 
honor  upon  those  two  surgeons.  [  Vide  Cases  CXL  V— 
CXL  F/.] 

All  other  methods  afiforded  by  surgery  for  the  relief  of  this 
defective  variety  of  organization  are  imperfect,  and  their  use 
often  completely  powerless. 

6.  M.  Martin,  Jr.,  a  surgeon  of  Lyons  in  France,  proposed 
in  such  cases  the  operation  of  incising  the  perinseum  through 
the  neck  of  the  bladder,  as  in  lithotomy,  for  the  purpose  of 
establishing  a  large  and  common  orifice  for  the  free  egress  of 
both  the  urine  and  the  faeces  which  might  pass  into  the  blad- 
der and  become  mixed  there.  The  orifice  he  expected  to  be 
kept  open  by  a  oanula  constantly  worn.  [Dlctionnaire  des 
Sciences  Medicales.  tome  XXIV.  p.  127.) 

This  proceeding  of  M.  Martin  should,  in  my  opinion,  never 
be  adopted.  If  it  is  not  as  dangerous,  it  is  at  least  more 
revolting  than  the  infirmity  itself.  The  greatest  objection, 
however,  to  the  operation  is,  that  in  the  largest  number  of 
cases  it  is  impossible  for  it  to  succeed,  indeed  it  has  not  even 


THE   SIXTH    SPECIES    OF   MALFORMATION.  233 

tlie  advantage  of  prolonging  tlie  life  of  tlu;  little  patient  for 
one  hour,  for  it  leaves  the  chief  difficulty  untouched,  wliidi  is 
neither  in  the  bladder  nor  in  the  urethra,  l)ut  in  the  naiiuw 
conical  rectal  canal  and  orifice  beyond  them.  I  have  already 
shown  that  the  rectum  in  the  majority  of  instances,  for  a 
greater  or  less  distance  before  entering  either  into  the  bladder 
or  the  urethra,  becomes  (juite  small  and  narrowed,  often  to 
such  an  extent  as  scarcely  to  admit  the  end  of  the  most  slen- 
der probe.  This  canal  in  its  congenital  state  of  constriction, 
together  with  its  recto-vesical  or  recto-urethral  opening,  would 
not  perhaps  be  touched  by  the  operation.  Even  should  the 
opening  be  urethral  and  be  divided  in  the  passing  of  the  knife 
into  the  bladder,  yet  the  difficulty  beyond  would  still  remain 
untouched. 

M.  Cavenne  performed  this  operation,  but  was  so  unfortu- 
nate as  to  lose  his  patient  in  the  course  of  several  hours  after- 
wards. As  his  case  is  interesting,  I  have  presented  it  in  full, 
translated  from  the  French.     [  Vide  Case  CXXXYIII^ 

It  is  not  to  be  understood,  however,  that  this  oj^eration  is 
never  successful,  for  in  cases  in  which  the  rectum  communi- 
cates directly  with  the  bladder  or  the  urethra  by  a  large  ori- 
fice, it  might  succeed. 

As  I  observed  before,  this  operation  should  be  repudiated, 
for  besides  its  other  numerous  inconveniences,  it  would  also 
add  those  of  rendering  the  patient  impotent,  and  leaving  him 
with  a  stercoraceous  and  urinary  fistula. 

7.  When  the  rectum  opens  into  the  vagina  the  indication 
is  the  same,  as  in  the  other  cases — that  is,  the  artificial  anus 
should  be  established  in  the  natural  situation,  by  opening  a 
new  route  from  the  end  of  the  rectum,  and  cutting  ofl*  the 
communication  with  the  vagina,  thereby  placing  these  two 
passages  in  a  condition  capable  of  carrying  on  their  respective 
functions,  independently  of  each  other,  as  they  should  do  in  a 
normal  state  of  the  parts. 

There  are  two  very  distinct  methods  of  operating  for  the  re- 


234  THE    SIXTH    SPECIES    OF    MALFOEMATION. 

lief  of  tliis  peculiar  deformity,  with  very  ingenious  modifica- 
tions. One  of  these  proposes  the  division,  and  the  other  the 
preservation  of  the  perinseum  and  septum.  Both  methods  find 
advocates  in  eminent  surgeons. 

8.  M.  Yicq  d'Azyr,  as  I  have  shown  in  the  sixth  chapter, 
has  recommended  the  division  of  the  posterior  wall  of  the 
vagina,  below  the  opening,  together  with  as  much  of  the  sub- 
jacent tissues  as  would  admit  of  the  introduction  of  a  canula. 
This  method  has  been  improved  by  Martin,  who  advises  that 
after  having  incised  the  entire  septum  from  above  downwards, 
and  from  before  backwards,  as  recommended  by  Yicq  d'Azyr, 
and  after  having  placed  a  canula  in  the  wound  to  form  a  con- 
tinuation of  the  rectum,  that  the  flaps  of  the  vagina  should  be 
united  in  front  of  the  canula,  by  points  of  suture.  M.  Vel- 
peau  is,  however,  of  opinion  that  this  last  stage  of  the  opera- 
tion, which  is  the  most  difiicult,  is  unnecessary — that  if  the 
tube  is  properly  adjusted,  the  reunion  of  the  divided  tissues 
in  front  will  be  effected  without  the  points  of  suture.  He 
advises  that  an  instrument  curved  backwards  in  the  form  of  a 
blunt  hook,  should  be  introduced  through  the  recto-vaginal 
orifice,  into  the  cul-de-sac  of  the  rectum,  and  its  extremity 
rendered  prominent  in  the  perinseum,  that  the  parts  covering 
the  extremity  should  be  divided,  and  that  a  tube  should  be 
introduced  into  the  opening  thus  formed.  {Nouveaux  Me- 
ments  de  Medicine  Operatoire.  tome  HI.  jp.  979.  Paris: 
1832.) 

By  this  method  recommended  by  M.  Yelpeau,  the  division 
of  the  recto-vaginal  septum  would  be  avoided,  which  would 
make  it  decidedly  preferable ;  but  it  would  not  be  practica- 
ble in  those  cases  in  which  the  rectum  opened  directly  into 
the  vagina  without  terminating  in  the  form  of  a  cul-de-sac. 

9.  Our  own  able  and  distinguished  fellow-countryman. 
J.  Ehea  Barton,  M.  D.,  of  the  city  of  Philadelphia,  was,  how- 
ever, the  first  surgeon  who,  so  far  as  my  knowledge  extends, 
proposed  and  executed  a  new  method  of  operating  in  such 


THE   SIXTH    SPECIES    OF   MALFOKMATloN.  235 

cases.  This  operation,  peculiarly  liis  own,  lie  sncccssfully 
executed  in  1823,  upon  a  female  child  a  few  moiillis  did.  Jn 
order  to  give  a  complete  exposition  of  his  operation,  1  have 
presented  a  full  report  of  his  case.     [  Vide  Case  CXC  VII.\ 

Dr.  Barton's  operation  in  a  similar  case  was  successfully 
executed  within  a  short  period  subsecpiently,  by  tlie  late  able 
and  highly  esteemed  Dr.  Parrish,  of  the  same  city.  I  have 
presented  the  case  of  Dr.  Parrish  in  full,  as  reported  hy  Dr. 
Satchell.     [Vide  Case  CXCVIII.] 

10.  Professor  Dieifenbach  has  proposed  two  methods  of  ope- 
rating in  these  cases,  one  of  which  diliers  but  little  from  that  of 
Dr.  Barton.  {Operative  Chiruryie.  B.  I.  .8.  676.  Leipzig  : 
1845.)  He  successfully  executed  one  of  his  methods  of  opera- 
ting upon  a  female  child  three  months  old.  I  have  presented 
this  case  entire  in  order  to  explain  fully  his  ingenious  method. 
[  Vide  Case  CXCIX.-] 

11.  Should  it  be  deemed  advisable  not  to  remedy  the 
deformity  at  once,  by  the  establishment  of  an  artificial  anus, 
on  account  of  the  feeble  condition  of  the  patient,  or  from  some 
other  cause ;  the  recto-vaginal  orifice  not  being  of  sufficient 
size,  might,  for  the  time  being,  be  dilated  by  proper  bougies, 
if  not  situated  too  far  back.  In  the  majority  of  instances, 
however,  the  recto-vaginal  opening  is  sufficiently  ample  for 
the  easy  evacuation  of  the  ffeces,  and  should  the  circular 
fibres  of  the  vaginal  orifice  of  the  rectum  exercise  to  some 
extent  the  functions  of  a  sphincter  muscle,  as  they  sometimes 
do  in  these  cases,  the  surgeon  could  still  with  greater  safety 
and  propriety  postpone  all  active  measures  until  the  patient 
had  attained  a  more  mature  age,  or  until  the  cause  which 
contra-indicated  the  operation,  in  the  first  instance,  was  re- 
moved. 


236  THE   SIXTH    SPECIES    OF   MALFORMATION. 

SECTION    III. 

CASES    AND     REMARKS.  » 

Many  of  the  following  cases,  reported  by  the  older  surgeons 
and  authors,  I  have  presented  as  briefly  as  possible,  inasmuch 
as  they  are  very  similar  in  character,  and  as  no  treatment  for 
their  relief  had  either  been  proposed  or  adopted. 

The  very  careless  and  indefinite  manner  in  which  some  of 
the  following  cases  are  described  and  reported  by  their 
authors,  makes  it  quite  difficult  sometimes  to  determine  posi- 
tively whether  the  rectum  terminated  in  the  bladder,  or  the 
urethra. 


(1.)  Cases  in  which  the  Rectum  Terminated  in  the 
Bladder. 

Case  CXXYI. — Holtzach  relates  the  case  of  a  male  child 
in  whom  the  anus  was  imperforate  and  the  rectum  opened 
into  the  bladder  by  an  abnormal  orifice.  i^Schenckii.  Obser- 
vationum  Medicoimm^  novarum,  admirdbilium  et  tnonstrosa- 
ram.  Lib.  HI.  Sect.  I.  Ohs.  CCXXVII.  p.  387.  Fra7wf. 
1609.   Folia.) 

Case  CXXVII. — A  description  of  the  case  of  a  new-born  male 
child  is  given  by  Osiander,  in  whom  an  imperforate  anus 
existed,  and  the  fieces  were  passed  by  the  urethra.  The  child 
died.  At  tlie  autopsy  it  was  found  that  the  rectum  commu- 
nicated with  the  bladder  by  a  short  canal  the  size  of  a  goose- 
quill.     {Denkwurdichheiten.   Band.  II.   8.  470.) 

Case  CXXVIII. — Murray  saw  a  male  child  who  presented 
an  imperforate  anus,  and  in  whom  the  rectum  communicated 
with  the  fundus  of  the  bladder.  The  child  lived  four  months, 
and  passed  fneces  and  gas  by  the  urethra.  The  fiscal  matter 
could  not  be  passed  through  this  small  channel  in  sufficient 
quantity,  which  finally  gave  rise  to  inflammation  and  mortifi- 


THE    SIXTH    8PKCIE8    OF    IIALFOKMATION.  237 

cation,   and   rcsnltcMl    in    doatli.       {Dh^ertatlo   Atresia    A/ii 
Vcisicalib;  sinyulari  obaei  vatione  llLaatrata.      Upsal :    1704.) 

Cask  CXXIX. — Morgagni  relates  tlie  case  of  a  <,nrl  wlio 
had  l)e6n  seen  at  ])()l()<;-iic,  wlio  liad  an  impertin-att'  anus  with 
an  ahnornial  opening  of  the  rectum  into  tiie  l)la(hler,  as  all 
tlie  fa3ces  passed  by  tlie  uretlira  completely  mixed  with  the 
urine. 

No  operation  is  said  to  have  been  performed  in  this  case. 
{Loc.  eit.  Epist.  XXXII.   Art.  4.) 

Case  CXXX. — Vollgnad  saw  a  new-born  male  infant  pre- 
senting an  imperforation  of  the  anus,  in  whom  the  faeces  were 
passed  by  the  urethra,  both  in  drops  and  in  large  (juantities. 
The  child  only  lived  a  few  days,  no  operation  having  been 
performed. 

At  the  autopsy  it  was  discovered  that  a  communication  be- 
tween the  rectum  and  the  bladder  existed,  {Miscellanea 
natur.  curiosa.  decur.  I.  arm.  I.  Ohs.  2.) 

Case  CXXXI. — Yan  Sanden  mentiouB  the  case  of  an  infant 
of  the  male  sex  in  whom  the  anus  was  imperforate  and  the 
rectum  communicated  with  the  bladder  by  a  narrow  canal 
the  length  of  the  thumb.  {Miscellanea  natur.  curiosa.  decur. 
Ill  ann.  IX.    Ols.  194.) 

Case  CXXXII. — M.  Desgenettes  reports  the  case  of  a  male 
child  in  whom  the  anus  was  imperforate  and  the  rectum  ter- 
minated in  the  bladder.  In  this  case,  in  addition  to  the  mal- 
formation already  named,  there  existed  imperforation  of  the 
prepuce  and  occlusion  of  the  mouth.     {Gazette  Salutaire.) 

Case  CXXXIII. — The  following  case  is  related  by  M.  Ber- 
lin, and  translated  from  his  memoir  in  the  Academy  of 
Sciences  by  Mr.  Thomas  Coj^eland,  who  published  it  in  his 
own  work.  {Ohsei'vcdions  on  the  Prineipcd  Diseases  of  the 
Hectum^p.ll^.     Second  Edition.    London:   1814.) 

"  In  the  montli  of  April,  1769,  an  infant,  five  days  old, 
was  brought  to  me  from  the  parish  of  Sens,  in  the  bishojjrick 
of  Rennes,  who  evacuated  the  meconium  by  the  penis  ;  and 
having  no  anus,  the  rectum  evidently  terminated  in  the  blad- 
der. I  saw  the  importance  of  the  complaint,  and  the  danger 
of  the  infant,  who  had  been  vomiting  three  or  four  days,  and 
the  abdomen  was  tense.  I  first  desired  the  parents  to  call  in 
M.  Thouin,  a  neighboring  surgeon :  when  he  arrived,  I  pro- 


238  THE   SIXTH   SPECIES   OF   MALFOEMATION. 

posed  to  make  an  incision  at  the  place  where  the  anus  should 
have  been,  which  was  farther  marked  out  by  a  bluish  spot. 
We  hoped  to  open  the  natural  passage  for  the  faeces,  and 
give  tliem  a  more  free  exit  than  through  the  bhidder  ;  and 
tiiat  eitlier  the  opening  in  the  bLadder  would  close,  or  that 
the  child  would  void  his  faeces  mixed  with  some  urine  by  the 
new  anus. 

"The  abdomen  being  very  hard,  and  the  child  vomiting 
the  milk,  and  even  its  excrements,  M.  Thouin  made  the 
incision  immediately,  in  the  presence  of  M.  Guiot,  a  surgeon 
in  the  neighborhood,  wlio  told  us,  he  had  performed  the  ope- 
ration twice  with  success. 

"  But  the  two  cases  related  by  M.  Guiot,  were  different 
from  the  present  one,  as  there  was  no  communication  with 
the  bladder ;  and  another  diversity  from  the  cases  he  de- 
scribed was,  that  in  this  case,  the  meconium  did  not  follow 
the  incision,  nor  could  the  rectum  either  be  found  with  the 
instrument,  or  the  finger,  the  best  of  instruments.  ^  We 
judged  it  necessary  to  plunge  the  trocar  through  the  incision  ; 
i't  was  passed  deep,  but  without  success  ;  which  was  the  more 
disconcerting,  as  we  were  as  certain  of  the  existence  of  the 
rectum,  by  the  evacuation  of  the  meconium  through  the 
bladder,  as  if  we  had  seen  it  with  our  own  eyes.  A  tent  w^as 
introduced  into  the  wound,  to  ])reserve  the  opening  for  fur- 
ther trials  which  might  suggest  themselves  on  reflect! ou. 
We  had  done  all  that  was  advised  by  authors,  in  cases  in 
which  the  rectum  does  not  descend  to  the  anus,  and  also  as 
much  as  the  debilitated  state  of  the  child  would  bear.  The 
child  was  taken  away  at  six  in  the  evening,  proposing  to_my- 
self  to  make  some  farther  attempts  the  following  day,  if  the 
condition  of  the  child  would  permit  it. 

"  I  requested  M.  Tliouin  to  see  him  early  in  the  morning. 
He  told  me  on  his  return,  that  the  child  was  so  ill,  that  he 
did  no  more  than  examine  it ;  but  that  the  meconium  had  de- 
scended on  the  tent. 

"The  child  died."  {MSmoire  de  VAcademie  Royale  des 
Sciences  de  Paris.     Annee  1771.) 

M.  Eertin  remarks  in  relation  to  such  cases,  that  a  free  in- 
cision should  be  made  into  the  bladder,  in  order  the  more 
effectually  to  evacuate  the  faeces,  and  reproaches  himself  for 
not  having  resorted  to  such  an  operation  in  the  preceding 
case.  From  this  it  is  evident  that  the  operation  of  M.  Mar- 
tin,   which   I   have   already  noticed,   was   proposed  by  M. 


i 


THE   SIXTH    SPECIES   OF   MALFORMATION.  239 

Bertin   as  early  as  1769,  consequently  M.  Martin  could  not 
liave  been  the  originator  of  it,  as  ho  claims  to  be. 

I  would  also  remark  here,  that  the  blue  or  livid  spot  which 
is  oftcMi  observed  at  the  normal  situation  of  the  anus  in 
imperforalion,  is  not  always  a  positive  evidence  of  confined 
meconium  tliere,  or  the  presence  of  the  end  of  the  rectum,  as 
is  generally  believed.  Dr.  Gay  reports  a  similar  case  in  this 
respect  to  that  of  M.  Bertin.     [  Vide  Case  CXLIXi\ 

Case  CXXXIY. — Wreisberg  mentions  the  case  of  a  male 
infant  in  whom  the  anus  was  imperforate  and  the  rectum 
opened  into  the  posterior  part  of  the  bladder,  by  a  small 
aperture.  [  Yide  Plate  ZZ,  Figure  2.] .  . . .  {Dlssertatio 
de  PrcEtematurali  et  raro  Intestini  Recti  cwm  lotii  Vesica 
coalitu^  et  independente  Ani  Dcfectu — Comment^  Societat, 
lieg.  Scientiar.  Gotthigens.  Vol.  I. p.  1.  1779.  Also — Com, 
m.e7itationum,  Medici  Physiologlci  Anatomlci  et  Obstetrlci 
Argumentl.  p.  172.  Tah.  VII.     Gottingens :  1800.) 

Case  CXXXY. — Casimir  de  Chonski  relates  an  interesting 
case  of  a  male  child  in  whom  the  anus  w^as  imperforate,  the 
rectum  absent,  and  the  colon,  after  descending  with  a  con- 
siderable curve,  passed  down  behind  the  bladder,  between 
the  ureters,  and  terminated  in  its  fundus  by  a  large  orifice. 
In  this  remarkable  case,  there  also  existed  bilobation  of  the 
bladder,  an  umbilical  hernia  formed  by  a  portion  of  the  small 
intestines,  together  with  a  preternatural  anus,  or  rather  a 
faecal  fistula,  situated  in  the  umbilical  region.  The  ureters 
were  very  much  dilated,  except  immediately  at  their  junction 
with  the  bladder,  where  they  were  of  the  normal  size.  [  Vide 
Plate  IX.,  Figure  3.] ....  {Dlssertatio.  I.  de  vitio  quodavi 
primcB  formationis  inferioreitTh  j^otissiinwn  tubi  intestinalis 
partem  et  vesicam  urinariam  spectante.  c.  ted).  Berol: 
1837.    Uo) 

Case  CXXXYI. — The  following  very  curious,  interesting 
and  unique  case  was  communicated  to  Mr.  Costello,  editor  of 
the  Cyclopfiedia  of  Practical  Surgery,  by  Mr.  Bennett  Lucas. 

"A.  B.,  a  male  infant  five  days  old,  presented  in  the  situa- 
tion of  the  anus,  a  red  fl.eshy-looking  tumor  about  the  size  of 
a  pea,  which  concealed  an  opening  only  capable  of  admitting 
a  small  tube,  about  to  the  depth  of  from  three  to  four  inches. 
Nothing  had  ever  been  passed  in  this  channel,  the  child  dis- 


240  THE   SIXTH   SPECIES    OF   MALFORMATION. 

clmrffinff  both  Its  urine  and  feces  tlirouiih  tlie  nrethra.  Botli 
testicles  had  descended,  and  a  congenital  hernia  existed  on 
either  side.  With  these  exceptions  the  infant  was  otherwise 
well  formed,  healthy  and  of  the  ordinary  size.  I  proposed  to 
Mr.  Kenii}^,  in  company  with  whom  I  saw  the  case,  to  perform 
an  operation,  with  a  view  to  establish  a  connection  between 
tiie  rectum  and  anal  aperture  ;  but  as  no  very  great  hope, 
much  less  decided  success,  could  be  held  out  from  its  per- 
f)rmance,  the  parents  objected  to  the  operation  being  at- 
tempted, and  the  little  patient  died  on  the  evening  of  the 
ninth  day  of  its  birth.  Two  days  before  the  infant  expired, 
its  scrotum  became  extended,  and  evidently  contained  a  fluid. 
An  incision  was  proposed  to  be  made  into  the  tumor,  but  it 
would  not  be  permitted. 

"  From  the  haste  attending  the  removal  of  the  parts,  I  lost 
sight  of  the  termination  of  the  ureters,  as  also  the  termiiui- 
tion  of  the  vassa  deferentia.  I  have,  however,  since  the 
accompanying  sketch  of  the  parts  was  taken,  slit  up  the 
remaining  portion  of  the  undivided  urethra,  and  with  the 
greatest  care  examined  its  mucous  surface,  and  also  the 
mucous  surface  of  the  bladder,  but  1  could  not  detect  any 
openings  besides  those  already  mentioned. 

'•As  the  child  passed  urine  through  its  urethra,  there  can 
be  no  doubt  but  that  this  secretion  was  received  into  the 
bladder ;  and  as  no  trace  of  any  opening,  except  the  recto- 
vesical, tlie  ano-vesical  and  the  urethro-vesical,  can  be  de- 
tected, the  urine  must  liave  been  conveyed,  in  the  first 
instance,  into  the  large  intestine,  and  thence  into  the  bladder 
by  means  of  the  recto-vesical  opening. 

"  I  am  unable  to  say  at  wliat  point  each  ureter  entered  the 
large  intestine,  having  brought  away  only  the  length  of  tlie 
intestine  shown  in  the  engraving,  which  includes  all  the  rec- 
tum, such  as  it  is,  and  a  portion  of  the  sigmoid  flexure  of  the 
colon  ;  and  so  far  as  this  much  of  the  gut  is  concerned,  the 
only  opening  it  presents  is  the  recto-vesical.  Tlie  ureters 
probably  opened  into  the  corresponding  ascending  and  de- 
scending portions  of  the  colon.  But  this  can  be  only  con- 
jecture. 

"  The  course  of  the  vassa  deferentia  was  also  destroyed  in 
the  liurry  of  removing  the  parts  ;  but  there  is  no  opening  in 
the  urethra,  bladder,  or  the  portion  of  large  intestine,  to  indi- 
cate that  they  terminated  in  any  of  these  organs. 

"The  urethra  does  not  present  a  trace  of  the  veru  mon- 
tanum.  I  also  looked  most  carefully  fur  the  prostate  gland 
and  vesicufe  seminales,  without  success. 

"  The   appearance   revealed   by   the   dissection  of  this,  I 


THE    SIXTH    SPKCIKS    OF   MALFOKMATION.  241 

believe,  unique   conJitic f  parts,  was  very   tliflerent   fioiii 

what  was  anticipated.  Although  tlie  infant  passed  both 
fajces  and  urine  throiii;li  its  urethra,  it  was  a  reasonable  infer- 
ence that  tlie  anal  orilice  conununicated  with  the  rectnni,  in 
consequence  of  the  depth  whicli  the  i)robe  passed  ;  the 
extreniity  of  tlie  probe  on  being  withdrawn,  being  sullied 
with  faices,  and  this  being  the  natural  ontlet  of  the  alimen- 
tary canaL  The  usual  orilice,  also,  and  the  canal  leading 
from  it,  being  so  uneven,  as  to  offer  a  serious  inii)ediment  to 
the  passage  of  the  faices  in  this  direction.  Notwithstanding 
it  was  evident  during  life  that  a  communication  must  have 
existed  between  the  bladder  and  the  rectum  ;  yet  under  the 
su])position  that  the  anal  orilice  communicated  with  the  rec- 
tum, all  hope  of  success  from  an  operation  which  had  for  its 
object  the  restoration  of  the  lower  portion  of  the  intestinal 
canal,  was  not  shut  out,  particularly  when  we  recollect  the 
rai)idity  with  which  abnormal  openings  in  children  close, 
wiien  once  the  cause  which  tends  to  keep  them  open,  is 
removed. 

"In  this  case,  however,  1  doubt,  if  any  operation,  even  were 
the  state  of  the  p;irts  beforehand  ascertained,  would  have 
been  attended  with  a  favorable  termination."  [Vide 
Plate  X,  Figure  1.]  {CydopcBdia  of  Practical  Sur- 
gery.   Vol.  1.  Article.  Bladder,  p.  472.  London,  1841.) 

Case  CXXXVII. — The  following  interesting  case  of  imper- 
forate anus  with  the  rectum  terminating  either  in  the  bladder 
or  in  the  urethra,  is  reported  by  Mr.  Miller,  of  Methven. 
This  case  was  allnded  to  in  the  fourth  chapter  of  this  work, 
when  speaking  of  the  difficulty  of  nuiintaining  a  perinatal 
artiticial  anus,  previous. 

"  In  the  nKmth  of  January,  1821,  Mr.  Miller  delivered  a 
yonng  woman  of  a  male  chdd.  Thirty  hours  after  birth  it 
was  discovered  that  the  child  had  no  anus,  and  there  was  no 
indication  of  the  place  which  the  anal  orifice  should  have 
occupied.  The  niecanium  passed  by  the  urethra.  Dr. 
Miller  made  an  incision  in  the  peringeuin,  at  the  normal  sit- 
uation of  the  anus,  of  an  inch  long  and  an  inch  deep  ;  and 
then  introduced  a  large  trocar,  such  as  is  commonly  used  in 
abd  aninal  paracentesis  ;  and  upon  the  second  attempt,  after 
having  pushed  the  instrument  to  the  guard,  the  end  of  the 
rectum  was  penetrated,  which  at  once  gave  exit  to  its 
contents." 

''  What  ordinarily  occurs,"  says  Dr.  Miller,  "  presented  itself 
here  also.     There   was  great  difficulty  in  keeping  the   anus 
open,   and   before   the  cliild   was  eight    months  old,   it  was 
16 


2-i2  TUE    SIXTH    SPECIES    OF   MALFORMATION, 

necessary  to  make  ten  incisions  with  the  bistomy.  Hardly 
had  the  boy  begun  to  walk  than  he  showed  a  fondness  for 
eating  cinders,  whicli  lodging  in  the  rectum,  obliged  fre- 
quent operations  for  his  relief.  In  one  of  these  the  bladder 
was  wounded,  and  from  that  time  the  urine  passed  in  small 
quantity  from  the  rectum,  but  the  larger  portion  still  followed 
the  course  of  the  urethra.  Laxatives  and  frequent  injections 
enabled  the  stools  to  be  made  with  tolerable  ease." 

The  child  was  four  years  old  when  one  day  the  mother 
found  difficulty  in  introducing  the  beak  of  the  syringe  into 
the  rectum ;  she  thought  she  felt  a  hard,  resisting  body.  She 
did  not  mention  tliis  to  Dr.  Miller ;  but  three  years  after,  a 
complete  obstruction  of  the  rectum  occurred,  accompanied 
with  the  most  severe  pain.  They  then  discovered  the  presence 
of  a  large  calculus  in ,  the  rectum.  The  anus  Avas  so  much 
contracted  that  it  would  hardly  admit  a  goose  quill.  — 
Dr.  Miller  enlarged  it  sufficiently  to  introduce  his  finger,  and 
he  found  the  concretion  was  large  enough  to  fill  the  hollow  of 
the  sacrum.  The  hardness  of  this  calculus  made  him  think  it 
only  possible  to  extract  it  in  fragments.  For  this  reason  he 
constructed  a  drill,  by  the  aid  of  which  he  could  easily  make 
a  hole  five-eighths  of  an  inch  in  diameter.  To  hold  the  stone 
during  the  drilling,  he  introduced  forceps  in  separate  parts, 
and  afterwards  united  them  when  in  proper  jjosition.  The 
amis  was  then  enlarged  in  the  antero-posterior  direction  to  a 
sufficient  extent,  and  the  drill  was  worked  until  the  stone  was 
completely  traversed.  Into  this  opening  a  strong  pair  of  poly- 
pus forceps  was  placed,  and  forcibly  separating  the  blades 
the  stone  was  broken  into  several  pieces,  each  of  which  was 
also  in  its  turn,  drilled,  broken  and  extracted.  The  operation 
lasted  two  hours  and  three-quarters.  All  the  fragments  being 
removed,  the  patient  was  put  to  bed.  At  the  end  of  ten  days 
he  was  able  to  rise  and  the  anus  had  returned  to  its  normal 
dimensions.  The  calculus  was  of  the  size  of  a  very  large  tur- 
key Qrfi:!;,  quite  hard,  and  very  rough  on  the  outside,  and 
seemed  formed  of  earihy  matter. 

Dr.  Miller,  having  left  the  country  for  several  years,  lost 
sight  of  his  patient,  but  hearing  mention  made  of  two  cases 
of  malformation  of  the  anus,  (one  of  which  presented  an  anus 
opening  into  the  bladder,)  and  upon  which  no  operation  was 
]>erformed,  being  considered  useless,  he  caused  inquiry  to  be 
made  to  learn  what  had  become  of  his  patient.  He  was  still 
alive,  and  Dr.  Miller  had  an  interview  with  him.  He  was  hi 
good  health,  and  had  never  complained  since  the  stone  was 
removed,  and  is  to  day  a  strong  and  active  farmer.  At  the 
age  of  twelve  years,  a  second  soft  stone,  the  size  of  a  chesnut, 


THE   SIXTH    SPECIES   OF   MALFORMATION.  248 

passed  M-itliout  pain,  but  he  had  h»st  it.  The  functions  ftf  iho 
bladder  and  tlie  rectum  were  performed  with  perfect  re^uhir- 
ity."  {Edlnbur(jh  Medical  and  Surgical  Journal.  No. 
XCVIII,  p.  r.i  1S29.  Also— Gazette  des  Uopitaux  de 
Paris.   No.  0  VL,  10  Septemhre,  1857.) 

Case  CXXXVIII. — M.  Cavenne,  a  physician  of  Laon 
(Aisne,)  reports  the  following  case  of  a  male  child  who  pre- 
sented an  imperforation  of  the  anus  and  rectum,  the  latter 
terminating  in  the  bladder  by  means  of  an  abnormal  cana-l 
and  orifice. 

"  Celine  Plainou,  38  years  of  age,  wife  of  Pierre  Cordevan, 
of  the  Commune  of  Brie,  Department  of  C'Aisne,  gave  birth, 
on  the  22nd  January,  1824,  at  eleven  o'clock,  A.  M.  to  a  male 
child,  seemingly  healthy  and  well  formed  ;  for  up  to  the  24th 
January,  the  second  day  after  its  birth,  the  parents  had  not 
discovered  the  infirmity  with  which  it  was  afflicted.  The 
cliild  sucked  well,  and  hitherto  the  urine  passed,  was 
unmixed  with  any  foreign  matter. 

"Soon  the  abdomen  became  swollen,  the  child  cried  out, 
and  appeared  to  suffer  much  ;  it  also  vomited  meconium  sev- 
ei'al  times.  The  health  officer  of  the  place  being  consulted, 
prescribed  a  bath  into  which  the  child  M'as  placed  for  some 
minutes.  The  same  symptoms  continued,  and  as  it  had  had 
no  evacuation  of  the  bowels,  it  was  resolved  to  administer  an 
enema ;  but  they  were  not  a  little  surprised  to  discover  no 
trace  of  an  opening  at  the  normal  place  of  the  anus,  nor  even 
in  its  vicinity.  On  leaving  the  bath  a  little  urine  was  passed, 
mixed  for  the  first  time  with  meconium.  The  passage  of  this 
foreign  substance  through  the  urethra  caused  swelling  of  the 
entire  penis,  which  was  temporarily  remedied  by  emollient 
applications. 

"I  was  called  in  on  the  mornino-of  the  25tli  to  examine  the 
cliild  and  employ  suitable  means  to  remedy  the  malformation. 
The  abdomen  was  distended,  slightly  tinged  with  green  and 
sensitive  to  pressure.  In  the  perinseum  I  discovered  only  a 
line  of  depression  extending  from  the  end  of  the  coccyx  to 
tlie  point  where  the  skin  of  the  scrotum  unites  with  that  of 
the  penis,  so  that  the  scrotum  instead  of  affording  a  single 
envelope  to  the  testicles,  formed  two  very  distinct  ones  ;  tlie 
prepuce  adhered  also  to  the  lower  half  of  the  gland.  I 
caused  the  child  to  lie  on  its  abdomen  so  that  the  pressure 
caused  by  this  position  might  render  the  place  ordinarily 
occupied  by  the  extremity  of  the  intestine  more  prominent, 
if  it  was  not  too  far  distant.  I  discovered  no  sign  of  its  exist- 
ence.    During  this  manoeuvre  the   child   vomited  meconium, 


24: i  THE    SIXTH    SPECIES    OF   MALFORMATION. 

whicli  also  passed  by  the  penis  mingled  witli  tlie  uriiie,  tiiitr- 
iiig  the  diapers  a  dee]j  green  since  its  exit  from  the  bath. 

"  Presuming  then  that  there  was  a  communication  between 
the  intestine  and  the  bladder,  forced  to  act  promptly,  since 
the  abdomen  was  rapidly  swelling,  while  the  meconium  was 
passed  by  vomiting,  it  became  necessary  to  choose  a  method 
and  to  put  it  into  execution.  To  establish  an  artificial  anus 
after  the  advice  of  M.  Dumas  would  only  j^artially  remedy 
the  malformation,  at  least  on  the  supposition  of  the  oblitera- 
tion of  that  portion  of  intestine  below  the  new  amis,  for  want 
of  which  a  part  of  the  meconium  must  continue  to  pass  into 
the  bladder.  I  therefore  gave  the  preference  to  the  process 
recommended  by  M.  Martin,  Junior,  a  surgeon  at  Lyons. 

"  To  perform  the  operation  the  little  patient  was  placed  on 
the  border  of  a  sufficiently  elevated  table,  furnished  with  a 
cushion,  and  a  cloth  folded  several  times ;  a  very  small  staff 
was  introduced  into  the  bladder  by  the  urethra  ;  the  thighs 
were  flexed  upon  the  abdomen  a  little  apart,  the  scrotum  was 
raised  with  the  left  hand,  and  the  perineum  rendered  promin- 
ent by  pressure  exerted  by  the  assistant  to  whom  the  staff  was 
confided.  A  longitudinal  incision  in  the  perinasum,  about  an 
inch  long,  allowed  me  to  pass  the  point  of  a  long  straight  bis- 
toury over  the  finger  nail  of  the  fore-finger  of  the  lefc  hand, 
into  the  groove  of  the  staff"  which  I  raised  towards  the  pubis, 
whose  direction  I  followed  in  order  to  penetrate  the  bladder 
and  incise  its  neck  by  the  withcb-awal  of  my  bistoury. 

Instead  of  the  great  quantity  of  meconium  which  I  ex])ected 
to  see  gush  out,  there  only  flowed  a  little  urine  mixed  with 
blood.  I  introduced  a  female  catheter  by  the  opening  just 
made,  to  make  sure  of  having  penetrated  the  bladder  ;  it  pen- 
etrated in  fact  to  a  greater  depth  than  the  blade  of  my  bis- 
toury had  done,  and  passed  around  the  cavity  of  the  organ 
very  freely,  always  arrested  by  the  resistance  of  its  walls.  A 
silver  canula,  two  inches  and  a  half  in  length,  surrounded 
with  fine  linen,  well  greased,  was  introduced  into  the  opening 
for  the  purpose  of  dilatation  and  to  arrest  the  hemorrhage  ; 
nothing  passed  the  canula  and  the  child  died  at  six  o'clock, 
P.  M.,  on  the  25th  of  January. 

"  Upon  opening  the  abdomen  there  flowed  out  several  ounces 
of  serous  fluid  of  a  greenish  color,  apparently  caused  by  the 
great  quantity  of  meconium  which  distended  the  large  intes- 
tines, as  well  as  the  greater  part  of  the  small  intestines. 

'■'  The  end  of  the  colon  cut  longitudinally  brought  to  view  the 
cavity  of  the  rectum  very  short,  terminating  in  a  cul-de-sac, 
from  which  there  issued  a   narrow    canal,  about  a   half  inch 


THE    SIXTH    SPECIES    OF    MALKOUMATION.  245 

long  coininuiiic!itin<i;  witli  tlie  bladder,  Ix'liiiid  tlic  iiccl<  of  that 
organ  by  an  opening  of  very  small  diameter. 

riirough  an  opening  made  in  the  anterior  j)art  ol"  tlu'  \\;dl 
of  tlie  bladder  uliieli  contained  no  ilnid,  was  seen  the  incision 
of  the  neck,  abont  tlwee  lines  in  length,  and  at  the  right  of 
this,  the  vesical  oju'iiing  of  the  canal  commnnicating  between 
the  intestine  and  the  bladder,  surrounded  with  a  slight  border 
which  seemed  to  perform  the  ottice  of  a  Sj)hincter.  I  conld 
only  ]>enetrate  tlie  (bict  from  the  cavity  of  the  intestine  to  that 
of  the  bladder,  by  the  aid  of  a  blunt  stvlet  a  little  larirer  than 
those  used  for  sounding  the  lachrymal  ducts.  {An'hicefi  Gen- 
erales  de  Medecine  de  Paris,     Annee  1824.  tome  Y.  p.  63.) 

Case  CXXXIX. — The  late  Dr.  John  11.  Steel,  of  the  Sara- 
toi:;a  Sprinf>;s,  New  Yoi'k,  reported  the  following  case. 

^"On  the  13th  of  April,  1833,  Mrs.  C,  a  strong,  healthy 
woman,  was  delivered  of  her  tenth  child,  a  fine,  fat  boy,  who 
weighed  between  eight  and  nine  pounds.  He  was  dressed, 
and  placed  in  bed  with  his  mother,  and  nothing  unusual  was 
observed  about  him  until  the  succeeding  day,  when  he 
became  restless  and  exceedingly  fretful,  and  although  he  was 
nursed  freely,  his  attention  to  the  breast  was  frequently 
interrupted  by  fretful  stai-ts,  accompanied  at  times  by  pierc- 
ing shrieks  and  noisy  crying.  His  diapers  were  observed  to 
be  frequently  wet,  and  when  removed  were  found  to  contain 
portions  of  feculent  matter,  of  a  natural  appearance,  and  in 
about  the  usual  quantity;  liis  restlessness  however  continued 
to  increase,  and  his  crj-ing  became  more  constant  and 
alarm  in  o;. 

''  On  the  second  or  third  day  after  birth,  it  was  discovered 
by  the  nurse  that  the  usual  aperture  for  the  evacuation  of 
the  contents  of  the  bowels  was  entirely  wanting,  and  that 
the  feculent  matter  which  had  appeared,  was  voided  through 
the  urethra  along  with  the  urine.  It  was  at  this  period  that 
I  Hrst  became  acquainted  with  the  case. 

"  On  removing  the  diaper,  about  a  spoonful  of  faeces  and 
urine,  of  the  consistence  of  thick  gruel  was  voided  at  once, 
apparently  with  some  effort,  troni  the  extremity  of  tlie 
urethra;  the  glans  penis  was  considerably  inflamed,  and  the 
child  cried  as  if  in  great  agony.  Several  other  and  stronger 
eflforts  were  evidently  made,  wdien  smaller  portions  of  fffices 
of  the  same  appearance  and  consistence  as  the  first  were 
excl'ided  and  the  little  sufferer  then  became  more  quiet. 

"  The  parts  behind  the  scrotum  were  perfectly  natural  in 
every  respect,  except  the  want  of  an  anus,  of  wdiich  there 
was  not  the  slightest  vestige,  the  spot  where  it  should  have 


2J:6  THE   SIXTH   SPECIES    OF   MALFORMATION. 

been  was  smooth,  and  of  a  uniform  color  with  the  adjacent 
parts,  the  sphincter  muscle  was  evidentl>^  wanting,  and  there 
was   nothing  to   indicate  an  accumulation   of  fseces  in  the 

vicinity. 

''The  examination  resulted  in  the  conviction  that  the 
intestine  did  not  extend  to  the  perinseum,  but  probably  ter- 
minated in  the  bladder  or  some  of  its  a])pendages ;  under 
this  view  of  the  case  any  attempt  to  form  an  artificial  anus 
would  have  been  useless,  if  not  absolutely  injurious.  The 
parents,  therefore,  were  instructed  to  keep  the  parts  clean, 
to  use  a  little  sweet  oil  about  the  glans  penis,  and  by  all 
means  to  keep  the  bowels  loose  should  any  tendency  to  con- 
stipation occur. 

"  For  the  first  three  or  four  weeks  the  child  continued 
fretful,  and  evidentlfy  to  decline  in  vigor  and  growth  ;  but 
from  tliat  period  to  a  short  time  before  its  decease  it  suffered 
but  little  apparently,  nor  did  its  growth  or  strength  seem  to 
be  at  all  impeded.  The  only  peculiarity  observable  was  the 
appearance  of  two  large  front  teeth  in  the  upper  maxilla, 
which  at  the  age  of  seven  months  were  as  large  and  fully 
grown  as  those  of  an  adult ;  they,  however,  in  the  course  of 
two  or  three  months  became  loose,  and  finally  dropped  out. 
In  the  latter  part  of  the  month  of  March  ensuing  its  birth  its 
bowels  became  obstinately  obstructed,  the  scrotum  enlarged, 
and  became  extremely  tender,  and  on  the  30th  of  the  same 
month  its  sufferings  were  terminated  in  death. 

"  At  the  antopsy,  on  removing  the  integuments  from  around 
the  body  of  the  penis,  which  were  considerably  swollen,  two 
ap2?le  seeds  of  a  large  size,  which  had  passed  through  the 
intestines,  together  "with  a  portion  of  the  capsule  or  hull 
which  surrounds  the  seed  in  the  core  of  the  fruit  were  found 
lodged  in  the  urethra  about  three-fourths  of  an  inch  from  its 
termination ;  they  were  so  situated  as  to  completely  obstruct 
the  passage,  and  a  small  opening  had  been  formed  immedi- 
ately behind  them  in  the  urethra  through  which  some  of  the 
contents  of  the  bladder  had  been  infused  into  the  cellular  tis- 
sue, and  extended  to  the  scrotum.  Inflammation  and  conse- 
quent gangrene  was  the  result,  and  to  this  may  undoubtedly 
be  imputed  the  immediate  cause  of  the  child's  death. 

"  Tlie  contents  of  the  abdomen  appeared  perfectly  natural, 
excepting  that  portion  of  the  intestinal  canal  termed  the  colon 
sinistrum  or  descending  colon,  which  was  found  to  be  entirely 
destitute  of  the  sigmoid  flexure  ;  the  gut  passed  along  the 
left  lumbar,  and  through  the  iliac  regions  in  nearly  a  straight 
line  to  the  neck  of  the  bladder,  into  which,  after  an  abrupt 
but  imperfect  curve,  and  being  suddenly  contracted  in  its 


THE   SIXTH    SPECIKS   OF    MALFOUMATION.  247 

(iiiiU'iisions,  it  was  inscrtoil  just  hi'liind  the  hasc  of  tlicyy/vAv- 
tate  {/land.  The  ajK'rture  wiiicli  iinit,i.'(l  the  gut  and  hhuhler 
of  urine  into  (»ni'  conmion  receptacle  for  their  respective  con- 
tents, was  of  suiliciont  (•aj)a('ity  to  a(hnit  a  iarti:;e  si/.i'd  gonse- 
(|uill  ;  throug'li  tliis  a[)erture  the  urine  found  a  rea<ly  egi-ess 
into  the  intestine,  where  becoming  united  with  the  contents 
of  that  receptacle  it  was  forced  back  to  the  bhidder,  and 
finally  expelle<l  through  the  urethra.  About  half  a  pint  of 
urine  and  l\eces  of  the  consistency  of  that  whicli  was  usually 
voided,  was  found  to  occupy  the  cavity  of  these  two  organs, 
and  was  readily  excluded  by  means  of  a  slight  pressure  on  the 
parts.  The  space  between  the  ])erinaHim  and  the  termination 
of  the  intestine  was  occupied  by  a  sofr,  fatty  substance,  but 
there    was   not    the    slightest   vestige    of    a   gut."       [  Vide 

Plate    X,   Figure   2.] (Atnerieafi    Journal   of  tJie 

Medical  Sciences.  No.  XXX.  p.  40-4,  Philadelphia .,  l^elru- 
ary,  1835.) 

Case  CXL. — M.  Cruvielhier  gives  a  very  interesting  in- 
stance of  a  fully  matured  male  ftetus,  in  which  was  presented 
an  imperforation  of  the  anus,  with  the  rectum  terminating  in 
the  bladder  by  a  very  small  canal,  at  the  posterior  extremity 
of  the  vesical  uvula.  In  this  case,  besides  the  malformation 
already  mentioned,  there  existed  a  very  remarkable  deformity 
of  the  pelvis  with  congenital  luxation  of  the  femur,  club-foot, 
&c.  The  perinasum  was  enormous  in  its  antero-posterior 
diameter.  There  was  not  the  slightest  trace  of  an  anns  and 
no  median  raphe,  but  all  was  smooth  in  the  ano-perinteal  re- 
irion.  At  the  extremity  of  the  coccyx  a  small  depression 
coidd  be  observed,  resulting  from  adhesion  of  the  skin  to  that 
point.  The  genitals  were  well  formed  but  were  pressed  to 
the  front,  and  the  scrotum  was  destitute  of  testicles.  [  Vide 
Plate  Xi,  Figures  1,  2,  3.]  {Anatomic  Pathologique  du 
Corpes  Humain.  Tome  I.  Livraison,  II.  Planche,  II. 
Figs.  1,  5,  6.     Bruxelles :  1833,  1834.) 

Case  CXLL — Baillie  saw  a  child  in  which  at  birth,  the  rec- 
tum opened  into  the  bladder.  The  deformity  was  of  such  a 
character,  he  observes,  as  neither  to  admit  of  a  remedy  by 
art,  nor  to  allow  of  life  being  continued.  {Morbid  Anatomy^ 
p.  165.     London:  1833;  hj  Wardrop.) 

Case  CXLII.— Dr.  Dorsey  remarks,  that  a  very  interest- 
ino- case  of  imperforate  anns  in  a  male  child,  is  related  by 
his  friend  Dr.  J.  A.  Smith,  in  the  second  volume  of  tlie 
"- Xcw  Yorl:  Medical  anl  Philosophical  Journal?'  In  fjiis 
case  the   rectum  terminated  in    the    urethr;i,   through    which 


248  THE    SIXTH    SPECIES    OF   MALFORMATION. 

canal  its  contents  were  evacuated.  An  unsuccessful  oi)era- 
tion  was  performed  tor  tlie  relief  of  the  patient;  the  wound 
healed,  but  M'ithin  a  month  the  child  expired.  No  dissection 
was  |)ermitted,  consequently  tlie  mode  and  place  of  commn- 
nication  between  the  rectum  and  the  urethra  or  bladder 
remained  uidvnown.  {Elements  of  Surgery.  Vol.  11.  Chap. 
LXIV.  J),  ttfjy,  Zrd  Edition,  Pfiiludelphia  :  1823.) 

Case  CXLIIL— The  following  case  was  communicated  to 
the  "  Boston  Medical  and  Sargioal  Journal,^''  by  Dr.  L.  W. 
Houghton,  of  Waterford,  Maine,  in  a  letter  dated  July  8tli, 
1847. 

"I  was  called  on  the  20th  of  last  month   to  see  an  infant 
child,  who,  the  messenger  said,   'seemed  to  have  no  passage 
from  the  bowels.'      The  child  was   some   eight  or  ten   liours 
old,  the  mother  having  been   attended   during  lier  confine- 
ment  by  a  midwife,  there   being  no  physician  within  some 
eight  miles  of  her  residence.     With  the  following  exceptions 
the    appearance's  of    the   child   were  healthful.  '    The   lower 
extremities   were   not  well   developed,    and   the  cuticle   M'as 
wanting  in  considerably  large  portions,  while  in  other  parts 
it  appeared  dry  and  horny.     Tlie  spine  also  terminated  from 
t\yo  to  four  inches  higher  up  than  natural ;  the  sacral  portion 
of  it,  if  no  more,  being  wanting.     The  rajyhe  along  the  perin- 
aeinn  extended  only  a  short  distance  back  of  the  scrotum,  and 
there  was  no  appearance  of  the  anus.     I  came  to  the  conclu- 
sion, that   from   the   external  appearance  of  the  child,  there 
was  malformation  of  the  pelvic  viscera,  or  that  some  portions 
were  wanting,  and  did  not   therefore  attempt  the   operation 
for  artificial  anus.     A  few  hours  after  I  left,  the   child   com- 
menced voiding  meconium  ]>er  urethra,  and  continued  to  do 
so  till  death,  which  occurred  forty-eight  hours  from  its  birth. 
"  Post-mortem  Examination. — I  found,  on  examination,  a 
termination  of  the  rectum  into  the  neck  of  the  bladder,  by  a 
very  small  opening,  barely  sufficient  to  admit  an  ordinary- 
sized   probe.     The  rectum,  besides   the   opening  already  de- 
scribed,  terminated  against   the  lower  lumbar  vertebra." — 
{Boston   Medical   and  Surgical   Journal.      Vol.  XXXVI., 
p.  520.     Boston  :   1847.) 

Cask  CXLIV. — M.  Amussat  reports  the  following  case  of 
imperforation  of  the  anus  and  rectum  in  a  new-born  infant 
of  the  male  sex,  in  which  the  rectum  opened  into  the 
bladder : 

"  On  the  seventh  of  May,  1842,  MM.  les  docteurs  Miquel 
and  Devilliers  sent  a  child  to  me,  about  forty-eight  hours  old. 


THE    SIXTH    SPECIES    OF   MALFORMATION.  249 

We  were  intonucd  tlioro  was  no  unus,  that  tlic  cliild  |>assc(i 
mecouiiiiu  with  the  uriiu',  and  that  on  account  of  tli is  cii-ciiin- 
Btance,  the  diapers  Leui<^  stained  yeUo\v,  they  had  onlv  jii-t 
discovered  tlie  nialt'orniatidii. 

''1  examined  the  chihl  in  tlie  ])resencc  of  ^1^[.  L.  lioyci, 
Fillios,  Grabowski,  Kontsoscki,  Silvestrc  Dii  Perrt)n  and  I.e 
Vail  hint. 

*'  No  anal  oj^enino;  existed  ;  the  raphe,  stroni;-ly  niarki-d, 
extended  beyond  the  coccyx,  and  tlie  perliueal  reg-iun  was 
everywhere  uniformly  developed.  Tlie  abdomen  was  n^xuch 
distended,  and  the  lower  part  tilled  with  seroslty.  The  urine 
was  of  a  yellowish  hue,  thick,  and  coIojxhI  the  linen.  Press- 
in<;'  Urmiy  on  the  abdomen  with  the  lingers  placed  on  the 
])erinix.'uui,  it  was  impossible  to  discover  any  kind  of  fluctua- 
tion. Although  the  conviction  existed  that  the  rectum  termi- 
nated in  the  bladder,  there  was  reason  to  suppose  that  the  end 
of  the  intestine  descended  to  the  lower  part  of  the  pelvis, 
either  directly  opening  into  the  fundus  of  the  bladder,  or  by 
dilatation  approaching  the  floor  of  the  perina3um  and  coccyx. 
lleasoning  from  this  supposition,  we  should  operate  from 
below,  and  endeavor  to  establish  the  anus  in  the  region  of 
tlie  coccyx,  before  attempting  to  make  an  artificial  opening 
in  the  left  lumbar  region  by  incising  the  descending  colon. 

"  An  incision  was  first  made  in  the  median  raphe,  of  suffi- 
cient depth,  extending  about  a  half  an  inch  from  before 
backward.  No  fluid  escaped.  Searching  under  the  coccyx 
nothing  was  found.  To  aid  the  exploration,  we  amputated 
the  cartilaginous  extremity  of  the  coccyx  and  explored  with 
the  index  finger  introduced  into  the  wound.  In  the  u^jper 
part  of  the  pelvis,  a  protuberance  was  seen  wdiich  seemed  to 
us  to  be  the  end  of  the  large  intestine.  We  now  hoped  to 
reach  the  end  of  all  our  eftbrts  ;  but  this  protuberance  having 
been  incised,  furnished  no  liquid,  and  yet  a  sort  of  mucous 
membrane  was  seen,  and  a  stilette  could  be  inserted  into  its 
cavity.  It  was  really  a  cavity,  as  it  seemed,  but  a  cavity  con- 
taining neither  gas  nor  fluid.  Finally,  after  many  useless 
endeavors  to  recognize  the  fluctuation  which  should  be  sensi- 
ble, if  the  intestine  had  been  in  the  upper  portion  of  the 
wound,  as  we  had  hoped  at  first,  the  operation  was  abandoned, 
by  reason  especially  of  the  feebleness  of  the  child,  and  from 
the  same  cause  we  deemed  it  advisable  to  operate  in  the  left 
lumbar  region  by  opening  the  descending  colon. 

"The  cluinces  of  life  in  this  child  were  very  small,  even 
before  the  operation  ;  lor  there  w^as  an  infiltration  of  the 
lower  part  of  tlie  abdomen,  an  Infilrratlon  announcing  already 
existing  disorders  of  that  region,  and  perhaps  of  the  respira- 


250  THE    SIXTH    SPECIES   OF   MALFORMATION. 

tion.  Its  condition  became  still  more  disturbed  after  so  lonij 
and  fruitless  an  operation.  A  gleam  of  hope  jet  remained 
frum  the  idea  that  the  end  of  the  intestine  might  become 
c'liiraored  in  the  wound  by  the  cries  and  efforts  of  the  child, 
and  that  then  we  might  open  it  and  tix  it  to  tlie  edges  ot 
the  wound.  But  we  were  disappointed  even  in  this  hope, 
and  the  child  died  thirty-six  hours  afterwards  without  our 
perceiving  through  the  opening  which  we  had  kept  open 
with  a  tent  of  charpie,  any  species  of  fluctuation  indicating 
that  the  rectum  terminated  in  the  pelvis. 

"  At  the  autopsy,  performed  in  the  presence  of  MM. 
Piett,  Filhos,  L.  Boyer  and  Le  Vaillant,  the  following  was 
observed. 

"The  large  intestine  was  distended  by  meconium  and  gas. 
It  jn-eserved  its  ordinary  relations  and  it  was  demonstrated 
that  the  left  lumbar  colon  was  fixed  to  the  posterior  abdom- 
inal M'all  and  that  the  peritonseum  did  not  come  at  least  one 
third  of  its  extent.  The  rectum,  M'liich  was  very  much  dis- 
tended, formed  a  voluminous  sac,  terminated  by  a  conical 
extremity  opening  into  the  bladder  between  the  two  ureters 
hy  h  narrow  strait  half  tlie  size  of  the  opening  of  the  neck 
of  the  bladder. 

"  By  the  perinseal  incision  which  was  made  in  order  to 
reach  the  end  of  the  lai'ge  intestine,  we  arrived  within  a  very 
short  distance  of  the  rectum.  Had  we  persisted  in  this  effort, 
it  is  })robable  that  Ave  should  have  reached  it."  {Troiseme 
Memoire  sur  la  Possibilite  d''etablir  une  ouverture  aitifciSUe 
sar  la  Colon  lomhaire  gauche  sans  oavrier  le  Peritome,  chez 
les  Enfans  imperfores.  Paris :  Annee  18^2.  Also  L'Ex- 
aminateur  Medical  de  Paris^  Annee  1843,  tome^  III.  p. 
215.) 

Case  CXLY.— C,  E.  Buckingham,  M.D.,  of  Boston,  Mass., 
communicated  the  following  case  to  the  "  Boston  Medical 
and  Surgical  Journal ;" 

"  William,  the  son  of  William  Lund,  was  born  on  the  6th 
of  December,  1851,  and  on  the  morning  of  the  following  day 
the  nurse  reported  that  there  was  an  obstructed  anus.  On 
examination,  the  cleft  of  the  nates  was  found  sufficiently 
imirked,  but  there  w^as  no  evidence  of  an  anus,  either  by  pro- 
trusion or  discoloration.  During  the  night  there  had  been 
r>ccasionally  bilious  vomiting,  and  latterly  straining,  as  if  to 
eviicuate  the  bowels.  There  had  been  no  discharge  of  urine. 
Ilad  taken  no  food  of  consequence,  but  had  tried  to  nurse, 
'the  countenance  looked  badly,  and  there  was  lividity  about 


TIIIC    SIXTH   SPECIES   OF  MALFORMATION.  251 

the  inoutli  and  ejos.  Was  somewluit  stuj.i.l ;  did  noi  cry,  Init 
was  constantly  nioaniiiiij. 

"O])oration  tliirty-two  and  a  half  lioiirs  after  l)irt]i,  with  the 
assistance  of  Dr.  IJenry  Osgood  Stone.  Tiie  child  was  licld 
upon  the  lap  of  the  nurse,  its  nates  resting  over  the  right 
knee,  and  the  knees  raised  as  for  lithotomy.  I  made  an 
incision  in  the  centre;  of  the  cleft  of  the  nates  from  the  scro- 
tum to  the  coccyx,  and  crossed  this  with  another,  at  right  an- 
gles, from  the  tuberosity  of  one  ischium  to  the  other.  The 
dissection  was  carried  on  with  a  sharp-pointed,  straight 
bistoury,  backward  and  a  little  to  the  left,  for  two  inches. 
No  evidence  of  the  neighborhood  of  the  rectum  being 
obtained  with  the  linger,  I  passed  a  hydrocele  trocar  into  the 
wound,  in  the  same  direction,  a  half  inch  further.  On  with- 
drawing it,  meconium  was  found  upon  it.  The  wound  was 
then  enlarged  with  the  knife,  and  a  female  catheter  M'as  intro- 
duced, through  which  an  enema  of  warm  water  was  adminis- 
tered. There  was  immediately  a  fair  discharge  of  meconium, 
and  a  slight  discharge  of  urine. 

"  The  child  cried  but  little,  and  the  whole  loss  of  blood  was 
not  much  more  than  two  drachms.  A  few  spoonfuls  of  milk 
and  water  were  given,  and  it  was  dressed  in  the  usual  manner, 
no  application  being  made  to  the  wound.  Half  an  hour  later, 
the  moaning  had  ceased,  the  child  looked  brighter,  and  there 
was  a  profuse  dejection. 

"5,  P.M. — Has  had  two  full  evacuations,  but  has  not  vomited 
nor  passed  urine.  At  5,  P.M.,  on  the  8th,  I  introduced  a 
sponge  tent  two  and  a  half  inches,  with  some  little  difticulty. 
During  the  attempt  at  introduction,  the  eftbrts  of  the  child  to 
evacuate  the  bowels  produced  an  audible  passage  of  air 
through  the  penis,  which  was  rendered  visible  by  the  spatter- 
ing of  urine,  and  perceptible  to  the  hand,  which  was  laid 
above  the  pubes. 

"  Dec.  9th. — Removed  the  tent,  immediately  after  which, 
he  passed  a  large  amount  of  almost  colorless  urine  in  a  jerking 
stream.  No  passage,  either  fluid  or  solid,  by  the  anus  at  the 
time. 

"  I  have  the  regular  reports  of  each  visit,  but  select  only 
such  as  are  of  particular  consequence. 

"  Dec.  1 4th. — Tried  unsuccessfully  to  introduce  a  bougie  of 
more  than  one-fourth  of  an  inch  in  diameter.  Umbilical  cord 
has  not  yet  separated. 

"  16tli. — Introduced  a  female  catheter  with  difficulty. 

"25th. — Free  dejection.  Passed  a  bougie  of  ebony,  seven- 
sixteenths  of  an  inch  in  diameter. 

"  27th. — In  pain  all   night.     Tumor  in  left  side  just  over 


252  Tiir:  sixth  species  of  malformation. 

short  ribs,  size  of  a  small  walnut.  ISTurse  says,  she  discovered 
it  last  night. 

u  29th. — Tumor  increasing  in  size.  Passed  bougie  of  25th 
again  with  case.     Some  bloody  pus  followed  it. 

''Jan.  1st,  1852. — Opened  tumor,  which  discharged  an 
ounce  of  pus. 

"  7th. — For  several  days  the  left  side  of  the  scrotum  has 

been  swelling. 

a  13tb. — Opened  small  abscess  in  front  of  scrotum.  Child 
weighs  nine  and  a  half  pounds,  an  increase  of  two  and  a  half 
pounds  since  birth. 

"  22d. — Bouo-ie  has  not  been  introduced  since  the  16th. 
Has  two  dejections  daily,  and  sometimes  more.  The  scrotal 
abscess  is  well ;  there  has  been  a  slight  gathering  again  on 
the  left  side,  which  broke  yesterday,  and  does  not  discharge 
to-day. 

"Feb.  13th. — ^N"o  bougie  since  Jan.  16th.  Three  dejections. 
Weighs  eleven  and  a  half  pouiids. 

"  March  lltli. — Gains  daily.  Nurses  well.  Bowels  open 
freely  every  day  without  medicine.  No  bougies  since  Jan. 
16th.     Has  gained  another  pound. 

"  Soon  after  this  last  report,  the  child  left  town  for  Gardi- 
ner, Maine,  and  returned  on  the  28th  of  May.  Saw  it  tliat 
afternoon.  Looks  well  and  is  fat  and  hearty.  About  the 
1st  of  May,  discharged  urine  and  fasces  mixed,  by  the  urethra ; 
but  has  not  since.  For  several  days  last  week,  had  diarrhoea, 
which  stopped  on  the  21st.  No  instrument  has  been  passed 
into  the  anus,  which  is  red  and  shining  about  its  edges,  and 
bled  a  little  on  separating  the  nates. 

"  Aue.  5th. — lias  six  teeth.  For  several  weeks  has  had 
diarrhoea,  and  feecal  matter  passes  by  the  uretlira,  as  much  as 
by  the  anus. 

"  In  the  fall  the  family  removed  to  Maiden. 
'  Oct.  21st,  1857. — Saw  Mrs.  Lund,  the  mother,  at  36  Lev- 
erett  Street.  She  informs  me  that  her  boy  upon  whom 
I  operated  is  still  living,  and  is  generally  in  good  health.  He 
occasionally  has  ]:)ain  in  the  pubic  region,  but  she  considers 
him  well.  There  is,  however,  at  times,  difficult  micturition. 
The  family  still  reside  at  Maiden."  {Boston  Medical  and  Sur- 
gical Journal,   Vol.  LVIL,  J).  Z'd4:.    JBonton  :  1S57 .) 

Case  CXLA^L — The  following  case  was  communicated  to 
the  "  BodiJii  Medical  and  Surgical  Journal^''  by  Noah  Gil- 
man,  M.  D.,  in  a  letter  dated.  South  Deerfield,  August  23rd, 
1853. 

"  While  residing  in  Frankfort,  Maine,  about  three  years 


THE    SIXTH  Sl'i:ciK8    OF    M.M.IOJi.MATIoX,  2o3 

since,  T  uttendcd  Mrs.  W.  in  her  first  coiifiiicineiir.  Slio  \v:is 
(U'liveriMl  of  Ji  lurj^^c,  ii])]>;uviitly  iu'iiltliy,  uiid  well-devcloiuMl 
male  cliild,  in  wliich  1  could  perceive  no  detect  whatever. 
Twenty -four  liours  afterwards,  was  notified  by  the  nurse  that 
the  child  had  passed  neither  urine  nor  fieces.  On  examina- 
tion, it  proved  to  bo  a  case  of  imjierf  >rate  anus,  of  a  very 
unusual  character.  The  rectum  liad  terminated  in  a  <al  de 
sac,  high  up  in  the  pelvis,  and  communicating  with  the 
bhidder.  There  was  not  the  slightest  rudiment  of  an  outlet 
to  the  gut,  nor  any  mark  to  indicate  where  it  should  be.  JS'o 
distension  of  the  integuments  denoted  a  pressure  of  the  fieces 
within.  The  genital  organs  were  somewhat  deformed.  The 
testicles  well  developed,  but  there  was  a  mere  apology  for  a 
j»enis,  with  the  urethra  ternjinating  near  its  root,  just  above 
the  scrotum. 

*'  Having  introduced  a  bent  silver  probe  into  the  bladdei-, 
its  removal  was  followed  by  a  jet  of  urine  and  thin  fieculent 
matter.  The  probe  was  also  covered  with  meconium.  In 
deciding  upon  an  operation,  I  reasoned  thus  : — As  it  is  uncer- 
tain how  far  it  will  be  necessary  to  dissect  in  order  to  reach 
the  rectum,  the  danger  of  wounding  arteries  beyond  the  reach 
of  the  ligature  will  be  very  great.  Should  it  be  necessai-y  to 
carry  the  dissection  any  great  distance,  the  patient  will  prob- 
ably die  in  my  hands.  And  then,  should  he  survive  the 
operation,  the  fact  of  the  connnunication  between  the  gut 
and  the  urinary  organs,  would  render  the  ultimate  success  of 
the  operation  quite  uncertain,  to  say  nothing  of  the  difficulty 
of  preserving  a  proper  opening.  On  the  other  hand,  the 
child  must  die. 

'-  With  the  advice  and  asssistance  of  Drs.  Edmund  ami 
Charles  Abbott,  I  made  an  incision  through  the  skin  and 
cellular  membrane,  from  the  extremity  of  the  coccyx,  along 
the  perinseuni,  about  tw^o  and  a  half  inches.  No  muscular 
fibres  were  divided.  Dissected  carefully  up  the  natural 
course  of  the  bowel  about  one  and  a  half  inches,  where  the 
rectum  presented  itself,  terminating  in  a  cul  de  sac  and  enor- 
mously distended  with  fseces.  This  was  freely  laid  open,  and 
a  copious  evacuation  ensued,  giving  entire  relief  to  the  little 
sufterer.  No  blood-vessel  requiring  ligature  was  wounded. 
The  divided  parts  were  kept  from  adhering  together,  at  lirst 
by  tents  well-oiled,  and  afterwards  by  a  tube  with  a  button 
on  the  end,  which  was  made  to  order.  Much  trouble  was  at 
first  experienced  in  retaining  the  tube,  as  its  introduction 
would  produce  violent  straining  and  evacuation,  but  the  parts, 
after  a  while,  became  accustomed  to  the  irritation.  In  a  few 
weeks   the  parts  were  entirely  healed,  and  an  artificial  anus 


25^  THE    SIXTH    SPECIES    OF   MALFORMATION. 

established,  to  all  appearance  as  good  as  natural.  Fortun- 
ately, after  the  operation,  no  faeces  ever  appeared  in  the 
urine,  nor  was  there  any  reason  to  believe  that  the  urine  ever 
passed  into  the  rectum. 

"  The  child,  at  the  age  of  one  yeai-,  was  remarkably  large 
and  vigorous.  The  family  removed  from  the  place,  and  1 
liave  not  heard  from  the  child  since.  As  the  sphincter 
muscle  is  wanting,  he  must  necessarily  experience  some 
inconvenience  on  that  account.  It  is  a  circumstance  worthy 
of  remark,  that  this  patient,  scarcely  twenty-four  hours  old, 
never  cried  during  the  operation,  thus  putting  to  shame  those 
robust  persons,  of  mature  age,  who  cannot  bear  the  extraction 
of  a  tooth  without  the  use  of  ether."  {Boston  Medical  and 
Surgical  Journal.      Vol.  XLIX. p.  115.     Boston:  1853.) 

Cases  CXLVII-CXLVIII.— M.  Yelpeau  says,  that  he  met 
in  his  practice,  with  two  male  children,  in  whom  the  anus 
was  imperforate  and  the  rectum  opened  into  the  bladder. 
{3fott,  Op.  cit.  I).  1086.) 

Case  CXLIX.— G.  H.  Gay,  M.  D.,  of  Boston,  Mass.,  on  the 
23d  of  November,  1857,  reported  the  following  case  to  the 
'-'•Boston  Society  for  Medical  Improvement.'''' 

"The  child  was  first  seen,  says  Dr.  Gay,  on  the  14th  No- 
vember, 1857,  about  sixty  hours  after  birth.  By  the  mother's 
account,  it  had  passed  nothing  from  its  bowels,  and  only  a 
slight  quantity  of  urine  from  the  penis,  and  was  in  nearly 
constant  distress,  with  occasional  nausea  and  the  vomiting  of 
a  greenish  fluid,  it  was  also  restless  and  crying  most  of  the 
time. 

"  On  examination,  there  was  the  brownish  discoloration  and 
puckering  of  the  skin  where  the  anus  ought  to  be,  but  no 
opening  could  be  found.  On  pressure  with  the  flnger,  active 
contraction  and  retraction  of  the  skin  followed,  indicating  a 
strong  muscular  power.  A  moderately  firm,  bluish  mem- 
brane, completely  closed  up  the  anal  aperture.  During  the 
longest  straining,  there  was  no  forcing  down  nor  protrusion 
of  this  membrane.  The  abdomen  was  swollen,  but  apparently 
not  tender  to  the  touch.  The  skin  of  the  face  and  upper  ex- 
tremities was  yellowish. 

"  A  probe  passed  through  the  penis  into  the  bladder  could 
not  be  felt  in  the  perinseum. 

"  The  parents  urged  an  operation. 

"  Operation. — The  membrane  being  freely  divided,  the  point 
of  the  little  finger  was  passed  through  the  opening,  but  no  ob- 
struction was  met  with,  no  cul-de-sac  could  be  felt,  nor  was 


TIIK    SIXTH    SPECIES    OF    MALFOliMATloN.  255 

there  aiij  impression  on  the  finger,  during  the  most  vioh-iit 
straining.  While  the  finger  was  in  the  opening  there  was 
strong  contraction  upon  it.  Tiie  finger  parsed  easily  to  the 
toj)  of  the  sacrum.  A  i)robe  was  then  passed  into  the  blad- 
dei",  and  traced  to  the  upper  part  of  the  sacrum  with  nothing 
intervening  but  the  thin  coat  of  tlie  bladder.  This  was  appa- 
I'cntly  closely  attached  to  the  bone,  as  notiiing  would  })ass  be- 
tween them.  The  bladder  was  not  distended.  As  far  as  the 
fore-finger  could  reach,  nothing  was  felt  but  the  probe  in  the 
bladder,  and  the  sacrum. 

"Under  the  circumstances,  nothing  further  was  attempted. 
The  parents  would  not  permit  an  operation  in  the  iliac  or 
lumbar  region, 

"  During  the  operation,  some  good-colored  urine  ^vas  passed. 
All  the  symptoms  that  weie  present  before  the  operation,  now- 
increased,  together  wntli  feecal  vomiting,  hiccough,  and  great 
yellowness  of  the  skin.  The  child  died  about  two  days  and  a 
half  from  the  operation.     No  autopsy  was  permitted. 

"  Befoi'e  death,  there  was  evidently  meconium  mixed  with 
tlie  urine,  from  the  appearance  on  the  cloths.  The  mother 
said  that  there  was  the  same  greenish  color,  though  not  sn 
marked,  once  before  the  operation.  As  there  was  nieconium 
evidently  mixed  with  the  urine,  the  intestine,  whether  it  was 
the  lower  part  of  the  colon  or  the  commencement  of  the  rec- 
tum, in  all  probability  terminated  at,  and  communicated  Mitli. 
the  upper  posterior  part  of  the  bladder,  and  was  out  of  the 
reach  of  any  operative  procedure  at  that  point."  {Records 
of  the  Boston  Society  for  Medical  Improvement^  Vol.  III.,]). 
156.     Boston:  1859.) 

Case  CL. — Professor  Gross,  of  the  Jefferson  Medical  Col- 
lege, Philadelphia,  reports  the  case  of  a  male  child  in  whom 
the  anus  was  imperforate,  and  the  rectum  terminated  in  the 
urethra  or  the  bladder.  Dr.  Gross,  in  this  case,  made  the  at- 
tempt to  reach  the  rectum  through  the  perinteum,  by  a  very 
deep  incision,  but  failed  to  reach  it.  The  child  survived  six 
weeks,  passing  daily  a  little  fsecal  matter  by  the  urethra. 

What  is  very  remarkable,  the  Professor  says  that  an  uncle 
of  this  child  had  lived  in  a  similar  condition  for  upwards  of 
thirty  years.  {A  System  of  Surgery,  Vol.  II,  Chaj).  XIII^ 
I).  765.     Philadelphia:  1859.) 


256  THE    SIXTH    SPKCIKS    of    ilALFoEMAXIO^". 

(2.)  Cases  in  which  the  Rectum  Tcrm'matedin  the  Vnthra. 

Cask  CLI. — Licetiis  relates  tlie  case  of  a  woman  who  luul 
from  birth  an  imperforate  aims,  with  an  abnormal  opeiiiniz; 
of  the  rectnm  in  the  urethra,  through  which  her  faeces  were 
voided.  {De  Moni^troruiii  Causis,  JSfatura^  et  Differeniiu. 
L',h.  11.  cap.  f3.  Patavii:  161G.  Uo) 

Case  CLII. — M.  Bravais  mentions  the  case  of  a  little  boy 
about  four  years  old  whom  he  dissected,  who  had  been  born 
with  an  atresia  ani  and  whose  excrements  had  altogether 
been  passed  by  the  urethra.  The  rectum  curved  round 
the  bladder  and  opened  into  the  urethra  by  a  narrow  prolonga- 
tion. {Actes  de  la  Societe  de  Sante  de  Lyon.  Amiee  1801, 
tome  11,^.  97.) 

Case  CLIII. — M.  Delesalle  mentions  the  case  of  a  female 
child  with  an  imperforation  of  the  anus,  who  passed  gas  and 
fluid  meconium  through  the  urethra.  After  a  bougie  was 
passed  in  for  live  days,  the  child  could  pass  a  few  drops  of 
urine.    It  died  on  the  tenth  day. 

At  the  autopsy  the  rectum  was  found  very  much  distended 
and  so  full  of  gas  and  meconium  that  the  bladder  was 
crowded  out  of  its  natural  situation.  When  the  rectum  was 
opened  and  washed,  it  was  found  that  it  lu\d  passed  down  and 
terminated  in  the  urethra  by  a  small  orifice.  {Bulletin  de  la 
Soelete  Medlcale  d'' Emulation  de  Paris,  Jui7i,  1824.) 

Case  CLIY. — Flajani  gives  the  description  of  the  case  of 
a  child  four  months  old,  which  presented  no  trace  of  an  anus, 
and  in  which  the  fsecal  matter  passed  out  by  the  urethra. 
Otherwise  the  child  was  well  formed  and  the  perinaeuin  and 
scrotum  were  entirely  normal.  Occasionally  there  was  swell- 
iuij;  of  the  hvpogastrfum,  and  the  child  seemed  to  suffer  much 
from  the  attempts  it  made  to  evacuate  its  bowels.  VVlien  it 
had  readied  the  ajje  of  seven  months,  search  was  made 
in  vain  for  tlie  rectum  by  two  punctures  m  the  normal 
position  of  the  anus.  Tlie  child  died  a  month  after,  jn-esent- 
ing  sym])toms  of  retention  of  faecal  matter,  considerable  and 
painful  tumet'action  of  the  abdomen,  ci'amps,  &c. 

At  the  autopsy,  the  colon  and  the  greater  portion  of  the 
intestines  were  found  filled  with  solid  excrement,  and  very 
much  distended,  'ilie  rectum  was  deficient  about  three 
inches,  and  terminated  in  a  canal  about  four  inches  long, 
which  passed  under  tlie  prostate  gland,  and  opened  into  the 
membranous  portion  of  the  urethra.     Tiie  recto-urethral  canal 


TiiK  SIXTH  si'i:('ii;s  of  M.\r,KOKM.\Tr(>x.  25" 

was  r(tni)(]    (•(.iiiplcU'lv   ohsti-iiclcd    Ky  a   clierfy  stoiio,  lod^'cd 
ill  it,  which  hati  hceii  swallowed  hy  the  chiM,  mid  w  liich  \va> 
the  imnu'diaro  cause  of  its  death.     [CollrzloiK'  (P Ossrrrd.-inni 
('    lilll'fisilone   di    C/tinmjla.  tome    I  V.    OKnerc    3l>.  Itomti 
1798-1803.) 

Cask  CLY. — Zacutus  Lusitauns,  of  Lisbon,  inoiitioiis  the 
case  of  a  male  cliikl  which  had  an  iiiipeii'orate  anus  witli  an 
abnormal  opening  of  the  rectum  into  the  uretlira,  as  the  treces 
made  their  exit  altogether  tlirough  tliis  passage  for  three 
months.  The  anus  was  closed  by  a  membrane,  which  was 
incised  when  the  chihl  was  three  months  old,  and  a  com- 
plete cure  was  the"  result.  {Prax.  Med.  Admir.  lib.  III. 
Ohserv.  72.) 

Case  CLYI. — Ilochstetter  reports  the  case  of  a  male  infant 
who  presented  an  imj^erforate  anus  with  an  abnormal  open- 
ing of  the  rectum  in  the  urethra.      {In  Med.     WochenUatl 

JVo.  18,  1780,  J^o.  19,  1788.) 

Case  CLYIL— Kretschmar  records  a  case  of  a  male  infant 
in  whom  the  normal  anus  was  absent,  and  the  rectum  opened 
into  the  uretlira.  {Ilorn^s  Archiv  far  die  Medicinsche 
Erfah'uiuj.  Band.  1.  S.  III.  Par  Ud.) 

Case  CLYIII. — Poulletier  saw  a  boy  three  years  old  who 
had  an  imperforate  anus  with  a  preternatural  opening  of  the 
rectum  in  the  uretlira.  {Dictionnairedes  Sciences  Medicales. 
tome  IV.  p.  157.) 

Case  CLIX. — Schenck  reports  the  case  of  a  new-born  in- 
fant in  whom  the  anus  was  imperforate  and  the  rectum  opened 
into  the  uretlira.  {Obseroatlonum  Medicorxim,  rai^arum,  no- 
V(frt/./n,  adniirahiliiitii^  et  rnonstrosarum.  Lib.  lY.  Obs. 
XXIV.    p-  55.     Framf:    1609.     Folia.) 

Case  CLX. — Somraering  cites  the  case  of  a  child  in  whom 
the  normal  anus  did  notexisr,  and  in  whom  the  rectum  opened 
into  the  urethra.  (Abildungen  und  Beschreibuncjen  eingiger 
MlmgiJjarten.     S.  53.     Mainz :  1791.     Folia.) 

Case  CLXI. — Lauremberg  also  relates  a  similar  case  to 
that  of  Sommering.     (Procrest  Anat.     lib.  I.    cap.  16.) 

Case  CLXIL— M.  Bonnet  reports  the  case  of  a  child  who 
presented  an  imperforate  anus  with  an  abnormal  opening  of 
17 


258  THE    SIXTH    SPECIES    OF    MALFORMATION. 

tlie  rectum  in  tlie  urethra.     {Archives  Generales  de  Medecine 
de  Paris.     Annee  1829.     totne  XX.    p.  576.) 

Case  CLXIII. — M.  Willaume  relates  a  similar  case  to  that 
of  M.  Bonnet.     {Journal  des  Progress,  tome  VIII.  2?.  238.) 

Case  CLXIY. — Randolphe  records  the  case  of  a  child  who 
with  an  imperforation  of  the  anus  had  an  •abnormal  opening 
of  the  rectum  in  the  urethra.  {Ency eloped ie  des  Soience 
Medicales  de  Paris.     Annee  1839.   jt?.  195.) 

Case  CLXV. — Dumas  saw  a  child  two  days  after  birth, 
which  had  no  anus,  but  in  place  of  the  anus  had  two  fissures 
of  the  skin.  The  space  wdiicli  they  enclosed  was  thick  and 
filled  with  hard  tissue.  The  urine  was  mingled  with  fsecal 
matter.  They  searched  in  vain  for  the  rectum  by  the  perin- 
eum. The  finger  introduced  by  the  periiiasal  wound  struck 
the  ischium.  The  cavity  of  the  pelvis  was,  therefore,  very 
naiT'Ow.  The  chikl  died.  At  the  autopsy  the  lower  part  of 
the  colon  was  found  distended  with  gas  and  fciecal  matter,  and 
jutting  against  the  abdominal  muscles.  The  rectum  seemed  a 
straight  sac,  movable  and  directed  towards  the  left  side  of  tlie 
neck  of  the  bladder,  and  opening  into  the  posterior  part  of  the 
urethra.  {Recueil per'iodique  de  la  iSociete  de  Medecine  de 
Paris,     tome  III.     p  46.) 

Case  CLXYI. — M.  Williams  communicated  a  case  of  im- 
perforation of  the  anus  and  rectum  in  a  male  infant  in  whom 
the  rectum  opened  into  tlie  urethra.  The  great  difiiculty  of 
passing  the  fteces  •  by  this  canal,  compelled  the  surgeon 
to  form  an  artificial  anus  in  the  perimeum  at  the  nor- 
mal ])lace  of  the  anus.  It  was  necessary  to  penetrate  to 
a  considerable  depth  before, the  end  of  the  rectum  could  be 
reached.  The  fseces  now  pass  equally  through  the  urethra 
and  by  the  newly-formed  anus.  {Revue  Medicale  de  Paris, 
Antice  1S-2C).  tome  III^p-  !"''"•) 

Case  CLXYII. — The  following  highly  interesting  case  was 
reported  by  M.  Iloux  de  Brignoles,  and  fully  illustrates  his 
peculiar  method  of  operating  in  such  instances.  The  ditficul- 
ties,  though  formidable,  were  all  overcome,  and  complete  suc- 
cess crowned  the  operation. 

"  The  case  was  that  of  a  new-born  male  infant  in  whom 
there  was  an  atresia  both  of  the  anus  and  of  the  urethra.  No 
trace  of  an  anus  could  be  discovered  in  the  perina?um  either 
by    the    ^ight   or    the    touch,    and    the    urethra    was    closed 


TI1I%    SIXTH    SPKCIKS    OF   MALFORMATION.  259 

by  :i  lliiii  iiicinhniiu  at  the  huso  of  the  <i;lanK,  coiistitiitIii«r  a 
kind  of  hypospadias.  Tlie  chikl  had  heeii  ahnost  wliolly  m'<r- 
lected  for  nearly  two  (hiys,  the  hibor  liavini^^  l)een  '8Ui)er- 
ititciidcd  by  an  iji;n(»raiit  midwife.  M.  Deveze,  a  iiei^ldx.rin^j; 
[)hysician,  was  first  ealled,  who  after  liaviiifij  aseertained 
the  real  nature  of  the  case,  and  finding  that  tlie  urethra  m-jls 
closed,  and  tliat  the  penis  was  in  a  state  of  erection,  at  once 
perforated  the  occluding  membrane  with  a  stilette,  and 
the  urine  was  voided,  lie,  however,  did  not  venture  to 
search  for  the  anus.  On  the  loth  of  May,  1833,  two  days  al- 
ter the  birth  of  the  child,  M.  Koux  was  called  in  consultation. 
The  countenance  of  the  infant  exhibited  signs  of  great  suffer- 
ing, the  skin  was  dry  and  yellow,  the  abdomen  tympanitic 
and  painful,  and  the  convolutions  of  the  intestines  could 
be  distinctly  traced  upon  its  surface  ;  there  was  frequent  hic- 
cup, with  vomiting  of  milk  and  sugar-water  which  had  been 
given.  Notwithstanding  the  difficulties  of  the  operation  under 
such  unfavorable  circumstances,  M.  Roux  determined  to  haz- 
ard the  performance  of  it,  in  order  to  save  the  child's 
life.  This  he  did  in  the  following  manner  : — He  placed 
the  little  j^atient  on  the  lap  of  an  assistant,  in  the  same 
manner  as  for  the  operation  of  lithotomy,  and  with  a 
scalpel  divided  the  skin  to  the  extent  of  about  an  inch, 
in  the  exact  line  of  the  raphe,  or  in  the  situation  which  the 
anus  ought  to  have  occupied.  On  separating  the  lips  of  the 
incision,  the  fibres  of  the  elliptic  muscles  of  the  sphincter 
could  be  seen  and  were  carefully  dissected  aside,  and  on 
arriving  at  the  levatores  ani  muscles,  their  fibres  were  also 
separated  towards  the  coccyx  for  fear  of  wounding  the  blad- 
der. Tlie  incision  at  the  depth  of  an  inch,  and  just  above  the 
last  layer  of  muscles,  terminated  in  a  mass  of  cellular  tissue, 
in  which  a  soft  and  fluctuating  tumor  was  perceptible  to  the 
finger.  The  scalpel  was  now  laid  aside  and  a  straight  bis- 
toury was  directed  to  the  spot  of  this  indication  of  tlie 
rectutn,  the  point  being  turned  obliquely  upwards  and  down- 
wards, in  order  to  avoid  the  bladder,  and  soon  entered  a 
cavity  which  proved  to  be  the  rectum.  For  the  purpose  of 
enlarging  the  intestinal  opening  thus  made,  the  handle  of  tlie 
bistoury  was  then  raised  and  the  blade  withdrawn  in  this 
position,  which  at  once  gave  exit  to  a  large  quantity  of  meco- 
nium, and  announced  the  success  of  the  operation.  Injec- 
tions of  marsh-mallows  water  were  now  thrown  up  to  wash 
out  the  intestine,  and  a  roll  of  lint  smeared  with  cerate  was 
introduced  into  the  wound  and  maintained  there.  This  kind 
of  dressing  was  con*tinued  for  two  weeks,  after  which  on  two 
(•ccasions,  granulations  sprouted  up  from  the   borders   of  the 


2(30  THE    SIXTH    SPECIES    OF   MALFOEMATION. 

wound,  and  narrowed  and  obstructed  tlie  newly  made  pas- 
sa<>-e  to  such  an  extent  that  the  f«cal  evacuations  became 
much  less  frequent,  and  were  voided  with  much  greater  tlitti- 
culty,  and  what  was  very  remarkable  at  the  same  time,  a 
small  quantity  of  fsecal  matter  was  discharsjed  through  the 
urethra  after  each  passage  of  urine.  In  the  first  instance, 
these  difficulties  which  seriously  threatened,  the  success  of 
the  operation,  were  for  a  short  time  entirely  overcome  by 
simply  enlarging  the  newly  made  opening  towards  the  coccyx 
with  "the  bistoury.  In  the  second  instance  however,  when 
the  granulations  again  returned  causing  the  same  difficulties, 
they  were  destroyed  by  the  nitrate  of  silver,  and  the  artiti- 
cial  aims  was  kept  open  and  enlarged  by  the  frequent  intro- 
duction of  bougies,  until  complete  cicatrization  took  place, 
and  the  faecal  matter  no  longer  came  by  the  urethra.  After- 
wards the  artificial  anus  fulfilled  completely  all  the  functions 
of  a  natural  one.  The  child  lived  and  enjoyed  good  health. 
[  Vide  Plate  X,  J^igure  3.J 

M.  M.  Capuron,  Eoux  de  Saint  Maximin  and  Moreau,  to 
whom  this  case  was  referred  by  the  Royal  Academy  of  Med- 
icine, in  their  report  highly  extol  the  method  pursued  in  it, 
by  M.  E.0UX  de  Brignoles.  {Gazette  MeJioale  de  Parin  : 
juin  28,  Annee  1834:.) 

Cases  CLXYIII— CLXIX— CLXX.— M.  Yelpeau  says, 
that  he  met  three  cases  in  children  of  the  n^de  sex,  in  which 
the  rectum  oj^ened  into  the  excretory  duct  of  the  urine. 
{Molt,  op.  cit.  I).  1086.) 

Case  CLXXI. — The  following  case  was  communicated  to 
the  "  Bostm  Medical  and  Surgical  Juurnal^ 

"  This  case  occurred  recently  in  the  practice  of  Dr.  J.  II. 
York,  of  South  Boston,  and  the  subject  of  it  was  a  male  child. 
Intestine  punctured  on  the  third  day,  with  a  trocar,  and 
about  two  ounces  of  meconium  drawn  off.  Canula  left  in  for 
a  week;  and  the  opening  being  then  dilated  with  a  sponge, 
the  fffices  passed  tolerabi}'  well.  At  the  end  of  six  or  eight 
weeks,  the  opening  having  been  still  further  enlarged  with  a 
knife,  a  silver  tube,  three  eighths  of  an  inch  in  diameter  was 
introduced  and  kept  in  for  about  a  year ;  the  faeces  mean- 
while passing  ofi:'  well.  Occasionally  the  instrument  was 
removed  and  cleansed;  but  once  or  twice  it  became  corroded 
and  obstructed,  and  then  it  was  observed  that  the  fieces 
passed  through  tlie  penis  ;  this  last  fact  being  first  noticed 
when  the  child  was  about  six  months  old. 

''  Three  or  four  months  before  its  death,  the  parents  removed 


TIIK    Sixril     9PKCIES    OK    MALFOUMATION.  2f>l 


the  tube,  without,  the  sanction  or  kno\vh'(l«r(',  of  Dr.  V.  ;  and 
sooii  after  tliat  time  the  t;ecc8  l)e<,^iu  tc^piis-s  thi-oiif,'h  tlie 
penis,  and  continued  to  do  so  ever  afterwards.  For  a  lime 
they  passed  also  throun-h  the  artilicial  openini,^  hut  for  the 
hist  two  months  not  at  aih  The  general  health  of  the  cliild 
was  quite  ii-ood,  and  it  died  at  last  from  the  eilects  of  a  fall 
that  it  received  a  few  days  before  its  deatii. 

"  Aulopxi/. — On  dissection,  tlie  rectum  was  found  to  be  very 
much  enlarged  and  moderately  thickened  ;  containing  some 
liquid  fjxices,  besides  a  quantity  of  foreign  matter.  The  oi)en- 
ing  into  the  urinary  |)assage  was  direct,  perhaps  two  lines  in 
diameter,  and,  upon  cutting  open  the  urethra,  found  to  be 
Justin  front  of  the  verumontanum.  The  opening  that  had 
been  made  during  life  luid  so  nearly  closed,  that,  \hough  air 
could  be  forced  through  before  the  parts  wqyq  cut  open,  the 
head  of  a  very  small  pin  could  not  be  made  to  pass.  Other- 
wise the  rectum  presented  no  unusual  appearance,  excepting 
a  soft,  fleshy  growth,  about  one  and  a  half  lines  in  dianieter, 
projecting  from  the  inner  surface,  situated  upon  the  anterior 
face  of  the  intestine,  a  few  inches  above  its  termination,  and 
divided  into  two  equal  parts  as  if  cut  with  a  knife.  The 
bladder  contained  some  liquid  faeces,  but  no  foreign  substan- 
ces such  as  were  found  in  the  intestine  ;  inner  surface  per- 
fectly healthy,  and  organ  otherwise  not  remarkable."  {Boston 
Medical  and  Surgical  Journal.  Vol.  XLIL  j>.  273.  Boston  : 
1850.) 

Case  CLXXII. — Mr.  Fergusson  records  the  case  of  a  male 
child  in  whom  the  anus  was  imperforate,  and  the  rectum 
opened  into  the  membranous  portion  of  the  urethra. 

"  An  opening  was  made  into  the  neck  of  the  bladder,  as 
was  supposed,  and  the  operation  was,  in  as  far  as  circum- 
stances would  admit,  perfectly  successful.  The  boy  lived 
and  throve  till  he  was  six  years  old,  when  he  died  of  disease 
of  the  lungs.  Although  it  may  be  doubtful  if  there  was  a 
sphincter  or  levator  muscle  here  originally,  he  had  the  com- 
mand over  the  aperture  and  the  urinary  apparatus  that  chil- 
dren usually^  possess.  Occasionally  when  his  bowels  were 
loose,  a  few  dro]3s  of  faeces  would  come  by  the  urethra,  and 
he  w^as  wont  also  to  discharge  part  of  the  urine  by  the  artifi- 
cial opening.  On  several  occasions,  small  hard  urinary  de- 
posits were  discliarged  from  the  anus,  and  I  had  to  extract 
one  about  the  size  of  a  hazel-nut.  Often  his  mother  had  to 
remove  small  seeds  and  barley  pickles  from  the  orilice  of  the 
urethra,  and  once  she  extracted  a  small  j)ortion  of  a  bone 
which  he  had  swallowed  in  his  food. 


262  Tin-:  bixth  species  of  malfokmation. 

"  On  inspecting  the  parts  after  deatli,  I  found  that  the 
bowel  terminated  in  the  membranons  portion  of  the  nrethra 
by  an  aperture,  about  the  size  of  a  lancet  puncture,  and  not 
in  the  upper  end  of  the  bladder,  as  was  originally  imagined," 
{A  Sy stein  of  Practical  Surgery.  4:th  American  JEdit.,p.  545. 
Philadelphia  :  1853.  Also.,  Edhiburgk  Medical  and  Surgi- 
cal Journal.  Vol.  XXX  VI.,  p.  ^Q'd.   1831.) 

Case  CLXXIII. — Dr.  Nagel,  Professor  of  Surgery  at  Clau- 
senbourg,  communicated,  on  the  25th  of  August,  1855,  to  the 
"  Society  of  Practical  Medicine  of  Berlin,''^  the  following 
case  of  imperforate  anus,  with  an  abnormal  opening  of  the 
rectum  in  the  urethra. 

"  This  was  the  case  of  a  male  infant  in  whom  no  anus 
existed.  A  small  tumor  a  little  elevated  above  the  skin  was 
the  only  indication  of  an  anus.  The  meatus  urinarius  was 
immediately  in  front  of  the  scrotum.  Hypospadias  and 
imperforation  of  the  anus  therefore  existed  at  the  same  time. 
Through  the  meatus  urinarius  small  cylinders  of  fsecal  matter 
passed  from  time  to  time,  mingled  with  the  urine,  which 
sometimes  however  passed  unmixed.  A  curved  sound  intro- 
duced by  this  passage  could  easily  be  so  turned  that  its  ter- 
minal extremity  was  felt  in  the  normal  position  of  the  anus. 
An  incision  was  made  upon  the  sound,  the  wound  was 
dilated,  and  a  pasteboard  cylinder  was  introduced  into  the 
rectum.  During  severral  days  a  small  quantity  of  fgecal 
matter  passed  by  the  urinary  meatus,  and  of  urine  by 
the  anus.  At  the  end  of  some  months  the  child  was  doing 
well,  the  anal  opening  M'as  sufficiently  large,  and  the  urine 
passed  by  the  urethra  alone,  and  the  Isecal  matter  by  the 
anus."  {liecherches  Cliniques  et  Critiques  sur  VAnus  Artifi- 
ciel.  Par  le  Dr.  Hermann  Friedherg.  Archives  Generales  de 
Medecine  de  Paris.    Mai,  1857,^.  580.) 

Case  CLXXIV. — M.  Godard,  a  resident  Hospital  student 
of  Paris,  presented  to  the  "  Societe  de  Biologie  de  Paris^''  in 
July,  1855,  three  anatomical  preparations  and  six  drawings, 
relating  to  three  cases  of  congenital  imperforation.  of  the  anus, 
which  came  under  his  observation  at  the  Hospital  Necker,  and 
at  the  Hospital  des  Enfants  Malades,  wathin  the  year  1855. 
These  cases  are  highly  interesting  in  several  respects.  They 
all  occurred  within  a  short  period  of  each  other;  they  were 
all  male  children  ;  the  rectum  in  each  terminated  very  smgu- 
larly  in  the  urethra  by  a  narrow,  pipe-like  prolongation,  and 
the  operations  in  each  were  soon  followed  by  death.  I  have 
presented  these  cases  almost  entire,  translated  from  the  origi- 


THE    SIXTH    8PECIKS    OK    M.M.I  ( (UMATION.  203 

rial.  Tlie  iolldwinoj  is  M.  (iodunrs  tliiid  case;  his  fust  aiul 
second  cases  will  he  touiid  in  tlie  chapter  on  yl/^Aw//?*^//?  yl/'//- 
ficial  Anus.     [  Vide  Cases  CCLXXIX—CiJLXX XI 1 1.^ 

"  Charles  rr(isj)er  Drcel  was  Ixini  on  the  2Tth  of  June,  IS.");'). 
On  ihe  day  after  his  birth  tlie  midwife  discovered  that  he  had 
no  anus,  and  tluit  tlie  mcconiuni  jiassed  by  the  nrethra  willi 
the  urine.  Tiiis  child  was  admitted  into  the  hall  Saint  Come 
of  the  Hospital  des  Enfanis  MahiJcs^  on  the  21>th  of  June; 
on  this  day,  as  well  as  on  the  i)recedin<i;,  it  had  several  times 
vomited  a  peculiar  matter,  having  the  odor  and  the  ai»j)ear- 
ance  of  meconium.  Pressure  upon  the  al)domen  caused  the 
meconium  to  be  discharged  in  jets  from  the  urethra.  M. 
Guersant,  the  surgeon  of  the  hospital,  made  an  incision  in  the 
pcrinaium,  three-eightlis  of  an  inch  long,  and  then  pushed  in 
a  trocar  in  the  direction  of  the  sacrum,  and  at  once  the  meco- 
nium flowed  through  the  camila.  This  opening  was  erdarged 
and  an  elastic  sound  was  inserted.  On  tlie  3Uth  of  June  the 
vomiting  ceased  and  the  intestinal  matters  passed  both  by  the 
nrethra  and  by  the  canula.  On  the  first  of  July  there  was  no 
change  in  the  condition  of  the  child,  and  on  the  third  it  died, 

"•Tlie  autopsy  was  made  on  the  fourth  of  July,  and  gave 
the  following  results: — The  peritoneum  was  slightly  vascular, 
and  in  the  pelvic  cavity  at  the  left  of  the  rectum  it  presented 
a  wound,  apparently  owing  to  the  puncture  of  the  trocar. 
The  su])erior  extremity  of  the  rectum  was  normal,  and  passed 
obliquely  from  above  downward,  and  from  left  to  right;  it 
adhered  behind  to  the  sacrum  and  coccyx,  and  in  front  was 
directed  towards  the  bladder  and  to  the  prostate,  both  of 
which  it  touched.  <,)n  the  left,  the  rectum  was  adjacent  to  an 
abscess,  which,  as  in  the  first  case,  was  the  result  of  the  punc- 
tures of  the  trocar  ;  the  wound  in  the  peritonaeum  proves  this. 
On  the  right  there  was  nothing  in  the  rectum  w^orthy  of  no- 
tice. The  inferior  extremity  of  the  rectum  terminated  in  a 
sack-like  dilatation,  and  presented  on  its  left  side  an  oldong 
openins:,  whose  greatest  axis  was  directed  from  before  back- 
wards.""  At  the  circumference  of  this  orifice  a  fibrous  cylinder 
was  sent  off,  which  extended  as  far  as  the  anal  region.  This 
cylinder  was  formed  by  a  condensation  of  the  cellular  tissue 
of  the  part,  and  was  the  result  of  the  operation.  Around  this 
canal  the  external  sphincter  could  be  dissected ;  tlie  fibres 
composing  it  were  in  layers  and  very  distinct.  This  muscle 
was  three-eighths  of  an  inch  in  height.  The  dilated  portion 
of  the  rectum  being  laid  open,  a  funnel-shaped  orifice  was 
observed  on  its  ant'erior  wall,  which  led  into  a  small  canal 
which  passed  under  the  prostate  and  opened  in  the  urethra 
just  in  front  of  the  urethral  crest.    The  peritonaium  descended 


264  TiiK  SIXTH  srivCiES  or  malformation. 

as  usual  along  the  niiterior  face  of-  the  rectum,  flexed  upon 
the  bladder,  and  at  the  point  of  reflection  was  seven-eigliths 
of  an  inch  distant  from  the  cutaneous  surface  of  the  perin- 
aeum."  {Oazette  MedicaU  de  Par'is.  A7inee  l^bh.  No.  44. 
p.  700.) 

In  relation  to  the  cause  of  the  formation  of  i\\Q  filjrous  cylin- 
der mentioned  in  the  preceding  case,  M.  Friedberg,  of  13erlin, 
in  the  pathological  pait  of  his  invaluable  Essay  on  Artificial 
Anus,  makes  the  following  comment:  "  M.  Godard  considers 
this  cylinder  the  result  of  the  operation.  I  contest  this  opin- 
ion for  two  reasons — First,  a  flbrous  cord  could  not  form,  by 
condensation  of  celluhir  tissue,  in  four  days  after  a  wound. 
Second,  M.  Godard  says  that  he  found  the  external  sphincter 
very  clearly  developed  around  this  cylinder,  as  well  as  fibres 
covering  it  to  the  height  of  three-eigiiths  of  an  inch.  It  evi- 
dently follows  that  this  fibrous  cylinder  descending  from  the 
corrugated  part  of  the  rectum,  was  actually  the  end  of  this 
intestine  which  had  been  obliterated,  and  upon  which  the 
movable  intestinal  canal  was  extended,  when  it  was  dilated 
with  the  accumulation  of  meconium." 

Friedberg  is  doubtless  correct. 


(3.)  Cases  in  which  the  Rectum  Terminated  in  the  Yagina. 

Cask  CLXXV. — Benivenius  describes  tlie  case  of  a  girl 
who  had  an  imperforate  anus  wdtli  an  abnormal  opening  of 
the  rectum.  This  girl,  two  days  after  her  birth,  commenced 
to  discharge  her  faeces  per  vaginam,  and  continued  to  do  so 
until  she  died,  which  event  took  place  in  her  sixteenth  yeai'. 
She  died  with  most  excruciating  colic  pains,  doubtless  in  con- 
sequence of  obstinate  constipation  and  induration  of  the  fieces, 
tor  she  usually  had  but  one  alvine  evacuation  in  eight  days. 
{Lihellus  de  Ahditis  nonnvllis  ac  tniixindis  Morhorum  Sana- 
tionum  Causis.  cap.  86.  Basil:  1529.) 

Cask  CLXXVI. — Van  Swieten  relates  the  case  of  a  young 
woman  who  was  afflicted  with  the  same  disgusting  malforma- 
tion as  the  one  mentioned  by  Betiivenius.  There  was  in  this 
case  an  iniperforation  of  the  anus  with  an  abnormal  opening 
of  the  rectum. 

No  surgical  operation  is  said  to  have  been  performed  either 
in  the  case  of  Benivenius  nor  in  this  of  Van  Swieten.     {Com- 


THE   SIXTH  SPKCIES    OF   MALFORMATION.  20; 


m 


enla/'id  in  Ihnnainu  Boerhaave  Aphorisinos  do  cognoHccuilis 
et  curandis  MorVis.  Lib.  IV.  Aph.  1340,  p.  575.  Ludo.  But. 
1785.)  ^  •" 

Cask  CLXXVII. — Mcrcuriulis  reliUcs  the  rciiKirkiiMc  c.-isc 
of   a    ytHiiiiJj   Jewess,  the  diiir'^litcr  of  a  i\-si<KMit  of    I'adiia, 
iiaiiUMl  Teiitouicus,  who  was   born  without  an   anus,  and  (lis 
chai'iiX'd  tlie  feces  altogether  through  the  vagina.     i^De  Mor- 
huH  Pnerot'iun.  Lib.  1.  c.  9,  Ve)ietu.s\   178.3.  4:(<t.) 

In  this  curious  and  fai--faini'(l  ease  of  that  day,  there  was 
an  iiu]ierforate  anus  with  un  abnormal  opening  of  the  rectum 
into  the  vagina,  tlirough  which  tlio  fiecal  matter  was  dis- 
chai'ged  ;  yet  strange  to  say,  that  tliis  remarkable  patient, 
with  this  great  affliction,  attained  to  the  extraordinary  age  of 
a  whole  century,  as  Morgani  testifies.  lie  also  says  that  Mer- 
curial is  pei'formed  no  o])eration  himself  in  this  case,  and  ad- 
vised the  father  of  the  girl  never  to  suffer  one  to  be  perfoi'med 
bv  any  one.  {De  Sidlbus  et  Causls  Morborxim  Epist. 
XXXII.  Art.  3.    Venellis    1761.  2  (o)n.  Folia.) 

Case  CLXXVIII. — De  Jessieu  mentions  the  case  of  a  girl 
seven  years  old,  whom  he  knew,  who  had  an  imperforate 
anus  with  an  abnormal  opening  of  the  rectum.  Tiiis  girl 
from  infancy  had  always  discharged  her  fiEces  per  vaginam. 
No  operation  is  mentioned  as  having  been  performed.  {^Ilis- 
toire  de  V Academic  des  Science.  AnnSe  1719.  p.  42.) 

Cask  CLXXIX. — Htesbart  says  that  he  saw  a  .young 
woman,  twenty  years  of  age,  who  passed  her  faeces  altogether 
per  vaginam,  the  anus  being  imperforate.  She  always  had 
excellent  health.  No  operation  was  performed.  (Jfiseel- 
lanea  curiosa  svm  ephem.  acad.  natur  curiosor,  decur.  II. 
anil.  X.  Observ.  1^.  p.  132.  1691.) 

Case  CLXXX. — Dodonpens  records  the  case  of  a  child  in 
whom  the  anus  was  imperforate  and  the  rectum  opened  into 
the  vagina.     [Anjiotationes  ad  jBeneviuin,  cap.  IX.) 

Case  CLXXXI. — Amatns  Lnsitanus  records  a  case  of  a 
female  infant  in  whom  no  natural  anus  existed,  and  the 
rectum  communicated  freely  with  the  vagina.  [Ouratlonum 
Medicinalium.     Cent.  II.  curat.  10.      Venet :  1653.) 

Case  CLXXXII. — Schenck  also  reports  a  case  of  a  female 
child  in  whom  no  normal  anus  was  ]^resent,  and  in  whom  the 
i-ectum  opened  in  the  vagina.  {Opus  ciiatum.  Lib.  III. 
Sect.  I  obs.  258.  p)-  458.) 


266  THE    SIXTH    SPKCIKS    OF   MALFOKMATION. 

Case  CLXXXIII. — Peteriiiann  observed  a  child  in  wlioin 
iu>  imtnral  anus  existed,  and  in  whom  the  rectum  opened 
into  the  va<2;ina.  {Observationes  Medlcm,  dec.  II.  Ohs.  2. 
Lipsm :  1707.) 

Case  CLXXXIV. — Ilartmann  saw  a  child  that  was  in 
excellent  liealtli  and  growing  rapidly,  who  presented  an 
imperforate  anns,  and  who  passed  the  faeces  altogether  per 
\  aginam,  {Miscellanea  curiosa  she  ephem,.  acad,  noiur  curi- 
osor,  decur.  II.  ann.  1691.  />.279.) 

Case  CLXXXY. — Alix  saw  a  chikl  in  whom  no  anus 
existed  naturally,  who  by  an  abnormal  anus,  discharged  the 
feces  through  the  vagina.  [Ohservat'iones  ChirurgiccB,  tome 
III  p.  203.     Altenhurg  :  1774.) 

Case  CLXXXYI. — Papendorf  observed  a  female  infant  in 
M-liom  no  normal  anus  existed,  whose  rectum  communicated 
with  the  vagina  by  two  abnormal  orifices,  and  through  which 
all  the  fsecal  matter  was  passed.  {Abhandlung  von  der  angeh- 
ohrnen  Yerschlicssung  des  Afters  hey  Kind r en.  Leipzig: 
1783.) 

Case  CLXXXYII. — ^Wandermonde  saw  a  female  child  in 
whom  all  the  faeces  were  passed  by  the  vagina,  there  being 
no  natural  anus.  {Recueil  Periodigue  de  la  Societe  de  Medi- 
cine de  Paris,  tome  VI.  p.  128.) 

Case  CLXXXYIII. — Arand  relates  the  case  of  a  female 
child  in  whom  there  was  an  imperforate  anus  and  a  communi- 
cation ol  the  rectum  in  the  vaginal  canal,  through  which  the 
fiEces  were  passed.     {Ohservat.  Med.  Chirurg.  obs.  IV.  jp.  28.) 

Case  CLXXXIX. — Fiirst  re2:>orts  the  case  of  a  female  child 
who  presented  an  imperforate  anus,  with  the  rectum  opening 
into  the  vagina.  {Miscellanea  curiosa  sive  ephcTn.  acad.  natur 
curiosor.  decur.  II.     arm  III     ohs.  112.) 

Case  CXC. — Bonn  records  a  case  in  which  the  anus  was 
imperforate  and  the  rectum  opened  into  the  vagina.  (Papen- 
dorf.     Opus  citatum.) 

Case  CXCI. — Kirsten  saw  a  child  whose  anus  was  imper- 
forate and  the  rectum  tei'minated  in  the  vagina.  {Act  nat. 
vur,     Llh.  IX.     ohs.  XI.    p.  24.) 


THK    SIXTH    SPKCIKS    OF    MALKcjltMATION.  267 

Cask  CXCII. — Ilocliard  oLsorvt'd  the  cnno  of  a  fcinalo 
iuttint  in  whom  tlie  {uius  was  iinpcrfonitc  aii<l  tin;  rL-ctuiii 
coimnuiucated  with  tlie  vagina,  {Jtmrnal  de  Medicine,  Ch'ir- 
xirgie,  Pharmacie.     tome  LXXXV.    p.  3 TO.) 

Case  CXCIII. — M.  Fournier  relates  a  very  interesting  case 
in  which  he  was  called  to  consult,  of  a  woman  who  had  been 
five  days  in  lal)or.  On  making  an  examination,  he  discovered 
no  trace  whatever  of  an  anus  in  its  natural  situation,  it  l)ein'>- 
congenitally  imperforate  ;  the  rectum  he  found  tilled  with 
foeces,  compressing  the  uterus,  and  tliat  the  abnormal  opening 
of  the  rectum  which  M^as  large,  entered  the  vagina.  He 
administered  an  enema,  after  which  the  fieces  were  evacuated, 
and  the  acconchement  safely  terminated.  {Dictlonnaire  des 
Sciences  Jledicales.  tome  IV.  p.  155-6.) 

Case  CXCIY. — Mr.  Cooke,  whilst  attending  a  woman  in 
labor,  who  was  nearly  forty  years  of  age,  discovered  that  with 
the  descent  of  the  foetal  head,  excrementitious  matters  escaped 
per  vaginam ;  and  also  that  a  congenital  communication 
existed  between  the  vagina  and  the  rectum,  sufficiently  large 
to  admit  two  fingers.  {English  Translation  of  Moryagni. 
Vol.  II.    I).  110.     Boston  :  1824.) 

Case  CXCV. — Mr.  Cooke  reports  the  case  of  a  female 
infant  wdiich  was  brought  to  him,  in  which  the  rectum  com- 
municated with  the  vagina,  through  wdiicli  all  the  faeces  Avere 
discharged.  An  anus  indeed  existed  at  the  natural  situation, 
but  so  rigidly  contracted  that  a  small  probe  could  scarcely  be 
introduced.     {Opus  citatum.) 

Case  CXCVI. — Mr.  Howship  reports  the  following  case  of 
imperforate  anus  with  an  anormal  opening  of  the  rectum  in 
the  vagina. 

"  In  1815,  I  was  requested  by  my  friend,  Dr.  Samnel  Merri- 
man,  to  examine  the  body  of  a  young  woman,  aged  seventeen, 
who  had  died  of  a  scrofulous  disease,  and  who  from  birth  had 
evacuated  her  stools  by  the  vagina  ;  although  there  Avas  in 
this  case  no  w^ant  of  power  of  retention. 

'■'-  Post-Mortem  Examination.  There  was  an  external  mark 
in  the  natural  situation  of  the  anus,  but  no  opening.  Upon 
laying  open  the  abdomen,  the  intestine  rectum  was  traced 
down  to  the  posterior  part  of  the  vagina,  to  which  it  was 
adherent. 

"The  vagina  being  removed  and  laid  open,  the  intestine  was 
found  to  open  upon  its  surface,  by  a  very  vascular  and  prom- 


268  Tii;<;  sixth  species  of  malformation. 

inent  sort  of  papilla,  situated  witliin  the  vagina,  near  the  os 
externum.'"  {^Practical  Ohservatlons  in  Surgery  and  Morhid 
Anatomy.    />.  321.     London:  1816.) 

Cask  CXCVII. — The  following  liighly  interesting  case  in 
whicli  the  rectum  terminated,  by  an  abnormal  opening,  in 
the  vagina,  was  communicated  to  the  ''Medioal  Recorder''  by 
the  able  and  distinguished  surgeon,  J.  Rhea  Barton,  M.D., 
formerly  surgeon  of  the  Pennsylvania  Hospital,  and  of  the 
Philadelphia  Alms-House  Infirmary. 

"Tiie  subject  of  this  imperfection  was  a  female  infant, 
already  six  weeks  old.  Upon  examining  the  part,  not  the 
slicjhtest  trace  of  an  anus  was  to  be  seen  ;  but  I  soon  observed 
tiie  faeces,  says  Dr.  Barton,  with  much  suneringto  the  patient, 
simultaneously  voided  with  the  urine  jy^'r  vaginam.  A  minute 
inspection  of  this  part,  led  to  the  discovery  of  a  fistulous 
aperture  through  the  recto-vaginal  septum,  and  communicat- 
ing with  some  part  of  the  intestine.  The  mother  evinced 
that  degree  of  distress  at  the  unhappy  deformity  of  her  off- 
spring, and  commiseration  for  its  sufferings  that  might  be 
expected  from  a  tender  parent,  and  was  extremely  solicitous 
for  its  relief.  Accordingly,  the  operation,  as  is  usually 
directed  in  cases  of  imperforate  anus,  was  performed  ; 
namely,  by  making  an  incision  through  the  parts  where  the 
anus  should  be,  tt:c.,  &c.  The  instrument  passed  into  the 
rectum,  and  upon  withdrawing  it,  fffices  esca])ed  freely.  The 
part  was  then  plugged  with  patent  lint  dipped  in  sweet  oil, 
to  prevent  re-union.  Not  many  days  before  the  wound  be- 
gan to  granulate  and  rapidly  cicatrize  ;  to  prevent,  therefore, 
its  closure,  a  piece  of  bougie  was  introduced,  and  brouglit 
out  of  the  vagina  through  the  original  opening  into  it.  Tliis 
tent  caused  much  irritation  and  suffering;  but  as  it  was 
deemed  advisable,  its  use  was  persisted  in  for  several  weeks. 
The  mother,  wiio  in  the  meantime  had  left  the  city  with  her 
infant,  findino;  it  productive  of  no  good  effect  removed  it ;  and 
the  part  soon  closing  up,  rendered  the  opei'ation  abortive. 

"When  the  infant  had  attained  the  age  of  nine  months,  the 
father  called  upon  me,  and  announced  the  increased  sufferings 
of  his  child,  owing  to  the  still  existing  defect,  and  greater  re- 
tention of  faeces,  from  their  becoming  more  consistent  as  the 
patient  grew  older,  stating  also,  that  without  tlie  effect  of 
aperient  medicines,  there  would  be  an  evacuation  not  oftener 
than  once  in  four  or  five  days,  and  sometimes  prolonged  to  a 
period  threatening  death. 

"  In  taking  the  case  into  further  considei'ation,  the  following 
mode  of  operating  suggested  itself  to  me,  as  one  promising 


TIIK    SIXTH    SPKCIES    OF   MALFORMATION.  2(^9 

SUCC0S8.  To  tak(^  tor  1113'  i^Miido  into  tlio  n-ctniii  tliu  ojx'iiiii:,' 
coniiuunicatini^  witli  the  v;i<,Mnu;  to  iiitroducu  into  it  adinjctor, 
and  with  a  bistoury  to  lay  open  the  vagina  and  inti-^runu'iits 
as  far  l)ack  as  the  pai't  where  the  amis  should  he  ;  ihcic  in 
remove!  a  small  pt»rtion  of  the  inte:^'uments,  if  necessary,  and 
to  dissect  down  until  I  came  to  the  tei-minatiou  of  the  i;ur, 
and  to  open  it  freely.  By  this  operation  the  antei-ior  houndary 
of  the  incision  would  be  the  listulous  openini>;  in  the  vaL;'ina, 
and  posteriorly  it  would  terminate  where  the  natural  outier. 
ou^ht  to  be  found.  The  subsequent  ti'eatment  t(^  consist  in 
endeavorini;  to  ])romote  granulations  and  the  cicatrizinir  of 
the  original  opening,  and  so  much  of  the  anterior  ])ortion  of 
i'.utislon  as  rendered  the  vagina  incomj)lete  ;  in  the  mean  time, 
to  keej)  the  remainder  open  until  this  shall  have  been  etfected. 
This  plan  was  pursued,  and  I  had  the  pleasure  to  succeed 
most  ])erfectly  in  all  my  views.  The  integuments  around  the 
incision  retracted,  and  thereby  obviating  the  necessity  of  re- 
moving them.  The  original  aperture  closed  up  with  that 
])art  of  the  incision  connected  with  it.  The  vagina  became 
complete,  and  a  route  direct  from  the  rectum  was  established, 
havino;  no  communication  whatever  with  the  vaii-ina. 

"  In  this  case  there  was  no  sjjlimcter  ani  muscle  ;  in  conse- 
quence of  which  I  had  nearly  been  deterred  from  the 
operation,  by  the  opinion  of  some  of  my  medical  friends,  wlii> 
nuiintained  that  even  thouii-h  I  should  succeed  in  establishin<^ 
a  direct  outlet  from  the  rectum,  the  patient  would  throughoiir 
life,  labor  under  the  lamentable  misfortune  of  being  uiuible 
to  control  the  evacuations,  tor  want  of  a  sphincter  muscle. 
Reflecting,  however,  upon  cases  of  fistula  in  ano,  where  this 
muscle  had  been  divided  by  the  bistoury,  I  recollected  that 
the  patients  even  there  were  enabled  to  exercise  a  limited 
degree  of  restraint  over  the  part  by  the  action  of  the  general 
muscular  coat  of  the  rectum,  or,  as  it  is  sometimes  described, 
the  internal  sphincter  muscle.  Under  a  belief,  therefore  that 
this  part  of  the  structure,  from  continued  use,  would  in  time 
assume  the  functions  of  a  proper  sphiircter,  I  operated  with 
confidence  of  success,  and  was  not  disappointed.  The  little 
patient  never  found  any  difficulty  from  that  source."  {Med- 
ical Recorder,  Vol.  V'lLp.2,bY.     P/u7.  182i.) 

Case  CXCYIII. — The  following  interesting  case,  similar 
to  that  operated  on  by  Dr.  Barton,  was  communicated  to  the 
~"  Medical  Recorder,^^  by  Dr.  Satchell,  then  House  Surgeon  to 
the  Pennsylvania  Hospital.  The  late  and  lamented  Di'. 
Parrish,  of  Philadelphia,  was  the  successful  operator  in  this 
case. 


270  THE  SIXTH    SPECIES    OF   MALFORMATION, 

"  Jane  Dimraick,  aged  about  fifteen  montlis,  was  admitted 
into  the  Pennsylvania  Hospital  on  the  6th  of  February,  1823, 
durin£:;  Dr.  Parrish's  tour  of  duty.  Slie  was  afflicted  with 
imperforate  anus,  the  fseces  being  passed  per  vaginam 
through  a  small  opening  situated  about  lialf  an  inch  from  the 
OS  externum.  The  depression  in  wliich  the  anus  should  have 
existed,  was  quite  smooth,  and  exhibited  no  mark  whatever 
of  the  proper  structure.  The  child  passed  her  faeces  with 
considei-able  pain,  at  intervals  of  ten  days  or  two  weeks, 
which  were  fluid  or  of  a  very  soft  consistence., 

"  Under  the  impression  that  the  rectum  terminated  in  a  cul- 
de-sac,  Dr.  Parrish,  on  the  18th  of  February,  performed  the 
following  operation.  A  probe,  having  a  curvature  suited  to 
the  purpose,  was  introduced  into  the  vagina,  thence  through 
the  orifice  of  communication  into  the  rectum,  so  as  to  pro- 
trude the  integuments  in  the  place  where  the  anus  should 
liave  been.  An  incision  was  then  made  upon  the  point  of 
the  probe  with  a  small  scalpel  through  tlie  integuments,  and 
the  opening  thus  formed  was  freely  enlarged  both  anteriorly 
and  posteriorly,  by  means  of  a  bistoury,  until  it  was  supposed 
that  the  intestine  was  opened,  no  discharge  of  fseces  being 
the  only  circumstance  of  evidencing  tlie  contrary.  Presum- 
ing, however,  that  the  rectum  was  freely  opened,  a  silver 
tube  somewhat  in  the  form  of  a  nipple,  with  a  curvature 
adapted  to  the  bowel,  and  with  shoulders,  anteriorly  and 
posteriorly,  for  the  purpose  of  confining  it  in  its  situation  by 
means  of  tape,  was  introduced  with  the  view  of  obviating  a 
closure  of  the  wound,  and  at  the  same  time  of  allowing  the 
evacuation  of  the  faeces.  But  in  the  course  of  two  or  three 
days,  it  was  positively  ascertained  that  tlie  rectum  had  not 
been  opened,  and  that  even  if  it  had  been  opened,  it  would 
have  been  utterly  impossible  to  have  prevented  a  reclosure 
of  the  gut. 

"  The  disease,  or  rather  the  malformation  being  unique  in 
the  practice  of  the  institution,  it  elicited  a  good  deal  of  atten- 
tion and  interest,  and  it  was  ultimately  agreed  to  attempt  a 
mode  of  cure,  which  had  proved  entirely  successful  in  a  very 
similar  case  that  had  occui'red  to  Doctor  J.  R.  Barton.  Encour- 
aged by  the  success  of  this  case.  Dr.  Parrish  performed  a  like 
operation  upon  his  little  patient,  and  liad  the  pleasure  of 
succeeding  to  the  extent  of  bis  wishes.  A  very  large  quan- 
tity of  impacted  faeces  was  found  to  occupy  tliQ  rectum,  and 
by  means  of  the  handle  of  a  teaspoon,  enemeta,  and  repeated 
doses  of  the  Olei  Picini,  the  bowels  were  thoroughly  emptied. 

"  On  the  6th  of  March,  two  days  after  the  last  operation,  the 
child  voided  an  unaltered  water-melon  seed,  which  must  hav 


TIIR    SIXTH   SPKCIKS    OF    MALKOUMATK  >X.  liTl 

been  in  the  bowels  since  tlie  ]»recc(lin<;  full  ;  and  inilccij 
there  is  reason  to  believe  that  she  never  passed  jmy  solid 
excrement.  The  faeces  were  at  first  of  a  dark  color,  and 
very  offensive,  bnt  soon  acquired  the  natural  yellow  appear- 
ance. The  wound  healed;  and  on  the  'JTtli  of  March,  three 
weeks  and  two  days  after  the  second  operation,  the  child  was 
discdiarii'ed  cured.  At  the  time  of  her  disciiar<ije,  she 
appeared  to  possess  considerable  jjowcr  over  the  anus,  and 
indeed  she  could  retain  or  discliari^e  her  faeces  at  pleasure. 

'•  We  have  every  reason  to  believe,  that  the  rectum  termin- 
ated in  this  case,  in  the  vagina,  and  not  in  a  cul-de-sac,  as 
was  at  tirst  presumed.  I  will  merely  add,  that  no  dressings 
were  used,  but  the  linger  lubi'icated  with  simple  cerate  was 
introduced  every  day  or  two,  in  order  to  do  away  any  ten- 
dencv  which  the  opening  mii^ht  have  to  heal."  {Medical 
Recorder,   Vol.   VII.  p.  359.  PA^/. .' 182J-.) 

Cask  CXCIX. — Pi-ofessor  Dieifenbach  reports  the  case  of 
a  female  child  three  months  old,  in  whom  there  was  not  the 
least  trace  of  an  anus  visible  external I3",  the  rectum  termin- 
ating in  the  vagina  in  its  posterior  wall,  by  an  abnormal 
opening.  In  this  case  Dieffenbach  performed  the  following 
operations  at  two  different  times.  He  first  introduced  a 
grooved  director  considerably  curved,  through  the  vagina 
into  the  recto-vaginal  orifice  ;  thrust  a  pointed  bistoury  imme- 
diately below  the  fossa  navicnlaris,  out-side  of  the  vagina, 
into  the  groove  of  the  director,  and  divided  all  the  cellulai- 
and  muscular  tissue  between  the  point  of  the  puncture  and 
coccyx.  He  then  dissected  off  the  end  of  the  rectum  from 
the  abnormal  opening,  and  isolated  it  for  some  distance 
from  the  surrounding  parts,  which  enabled  him  to  draw 
down  the  freed  end  of  the  bowel  and  attach  it  to  each  edge 
of  the  cleft  perineum.  The  cut  edges  of  the  rectum  united 
to  the  skin,  and  the  recto-vaginal  aperture  closed  very  com- 
pletely, after  having  been  occasionally  touched  with  the 
nitrate  of  silver. 

Three  weeks  after  the  first  operation,  and  after  complete 
union  of  all  the  wounded  parts  had  taken  place,  he  attempted 
the  formation  of  an  artificial  perina3um.  He  commenced  by 
finishing  the  separation  of  the  superior  wall  of  the  rectum 
from  the  vagina  with  a  bistoury.  This  portion  of  the  rectum 
thus  set  free  in  the  centre,  contracted  considerably,  and 
receded  about  half  an  inch.  The  deep-seated  soft  parts  were 
brotight  together  by  a  needle-stitch,  whilst  the  edges  of  the 
wound  were  united  by  two  short  hare-lip  pins  and  the  twisted 
suture.      The  cure  was  completely   successful.      {Oher  die 


272  THE    SIXTH    SPECIES    OF   MALFOKMATION. 

VerseJiUessung  des  Afters.     In  Ileckers  literarischcn   Anva- 
len.    January.,  1826.  8.  31.) 

Case  CC— AslibcU  Smith,  M.D.,  of  Salisbury,  IS^ortli  Caro- 
lina, reported  tlie  following  case  : 

"This  was  the  case  of  a  female  infant.  Tlie  accouchement 
of  the  mother  was  at  the  end  of  the  ordinary  period  ;  of  the 
lir;;t  child,  easy,  and  presenting  nothing  worthy  of  record. 
The  child  was  of  the  usual  size,  healthy,  and  exhibited  no 
malformation  except  the  one  which  I  am  about  to  describe. 
Some  time  after  its  birth,  it  was  discovered  that  an  anus  was 
wanting,  and  that  the  excrements  were  voided  through  the 
vagina.  The  patient  continued  to  void  her  fteces,  in  this  way, 
till  she  was  four  months  old,  lacking  five  or  six  days,  when  an 
operation  for  artificial  anus  was  performed. 

"  At  the  time  of  the  operation,  July  7,  183-1,  the  general 
health  of  the  little  patient  was  good,  unless  we  except  a  some- 
what costive  habit.  It  has  been  raised  partly  by  the  bottle, 
in  consequence  of  a  deficient  secretion  of  its  mother's  breasts; 
but  the  derangement  of  its  health  was  not  greater  than 
almost  invariably  accompanies  imperfect  nourishment,  in  the 
way  instituted  by  nature.  Tlie  genital  organs,  on  careful 
examination,  did  not  present  eortcriiallij  anything  remarkable 
or  abnormal.  The  clitoris,  the  labia,  the  fourchette,  the 
meatus  urinarius,  were  of  the  usual  size  and  well  formed. 
The  hymen  existed,  but  was  small.  Whether  the  os  tinea?, 
and  of  course  the  womb,  existed,  I  could  not  conveniently 
discover.  The  rectum  terminated  in  the  posterior  and  upper 
portion  of  the  vagina.  The  perinoeum  offered  no  trace  of 
anus,  except  it  were  that  the  place  it  should  have  occupied 
w'as  thought  to  be  marked  by  a  very  slight  brownish  discolor- 
ation. 

"  The  operation  was  performed  in  the  usual  way.  Assisted 
by  my  friend.  Dr.  E.  R.  Gibson,  I  made  an  incision  in  the 
place  commonly  occupied  by  the  anus,  and  continued  it  along 
the  direction  of  the  coccyx  until  I  arrived  at  the  rectum. 
The  depth  of  this  incision  was  from  nine  to  twelve  lines. 
The  rectum  was  thus  opened  to  the  extent  of  two-thirds  or 
three-fourths  of  an  inch,  and  some  fffical  matter  was  discharged 
through  the  incision.  A  transverse  incision  was  made,  and  a 
tent  smeared  with  sweet  oil,  was  placed  in  the  wound  to  keep 
it  open.  No  untoward  symptom  succeeded  the  ojxn-ation  ; 
the  inflammation  was  moderate,  and  did  not  extend  beyond 
the  wound,  nor  in  any  degree  complicate  the  general  health. 

'•  About  seven  months  after  the  operation,  February,  18^."^, 
I  again   saw  the  patient.     The  artificial  anus  was  perfectly 


THE    SIXTH    SPECIK8    OF   .AIAhroKMATlON.  273 

healed,  :in<l  wuild  then  easily  admit  an  iirelhni!  I.un^noof  the 
lai-<,a'st  size,  beiii_j;-  of  less  dimensions  ihan  the  ()ri^ri„arincisi..n 
in  consequence,  as  i.s  pi-obabk-,  of  tiie  ditlicuhy  in  maintainin-r 
the  tent  in  its  phico._  The  tent  had  been  for  a  lon^-  time-  di" 
used,  and  the  artificial  anus  showed  no  disposition  t(:)  conliact 
further.  Its  parietes  were  covered  with  a  smooth  and  ai)i)a- 
rentlj  or<j:anized  membrane.  The  fieces  were  discharn-Jd 
partly  through  the  recto-vaginal  canal.  It  was  intended  to 
enlarge,  at  some  future  time,  the  artificial  anus,  but  the 
patient  died  of  an  acute  disease  some  weeks  subsecpientlv  to 
the  last  date,  or  more  than  eight  months  after  the  operation. 
No  cadaveric  examination,  I  understand,  was  made."  {Ainer- 
lean  Journal  of  the  Medical  Sciences.  No.  XXXIV..  p  341 
Februarxj,  1836.) 

Case  CCI. — The  celebrated  M.  Eicord,  of  the  Hospital  du 
Midi  of  Paris,  relates  a  very  interesting  case  of  a  courtesan 
twenty-two  years  of  age,  in  whom  the  rectum  terminated  in 
the  lower  and  back  part  of  the  vagina  by  an  orifice  which 
permitted  the  introduction  of  the  index  finger  without  pain, 
who  had  come,  at  the  request  of  one  of  her  lovers,  to  consult 
him  as  to  whether  or  not  she  had  a  Mennorrhagia. 

"  M.  Ilicord  introduced  the  speculum  easily,  and  at  first 
nothing  abnormal  was  seen.     The  depth,  however,  to  which 
the  instrument  was  carried  without  meeting  the  neck  of  the 
uterus,  began  to  excite  some  astonishment,  when  a  lump  of 
fiBcal  matter  was  brought  into  view,  simulating  to  the  touch, 
the  OS  uteri ;  and  also   some  grape  seeds,  at  first  taken  for 
vegetations.      Some   malformation   being  now  suspected,  a 
more  careful  examination  was  made.     Tlie  external  organs 
were  natural,  but  there  was  no  anus,  the  place  where  it  ought 
to  be  being  marked  by  a  brown  spot,  irregularly  radiated  and 
of  the  size  of  a  shilling.     The  ring  of  the  vulva  did  not  pre- 
sent any  carunculiB  myrtiformes,  had  eccentric  folds  of  mu- 
cous membrane,  and  possessed  a  much  greater  contraction 
than  the  natural  constrictors  of  the  lower  part  of  the  vagina, 
but  less  than  the  sphincter  ani.     Beyond  this  vulvar  ring,  the 
finger  passed  easily  into  the  recto-vaginal   canal.     No  trans- 
verse rugse  were  found  as  usual  in  the  vagina,  and  the  specu- 
lum, when  introduced  to  its  full  length,  was  arrested  by  fiecal 
matter.    No  trace  of  the  uterus  could  be  seen  or  felt.    By  her 
account,  the  fseces  were   always  passed  by  the  vulva,  and 
were  perfectly  under   the    command  of   volition,  but  flatus 
sometimes  escaped  involuntarily.     When  the  faeces  were  at 
the  vulvar  ring,  she  felt  a  desire  to  go  to  stool,  and  when  this 
desire  was  satisfied,  the  finger,  introduced  as  far  as  possible, 
18 


274  THE    SIXTH    SrECIES    OF   MALFOKMATION. 

no  longer  met  with  any  obstacle.  An  injection  was  always 
used  ini mediately  after,  and  she  was  careful  in  keeping  her- 
self clean.  Menstruation  had  never  shown  itself  under  any 
form,  and  no  trace  of  blood  was  ever  found  in  the  urine  or 
fffices.  Although  she  had  lived  with  one  of  her  lovers  for 
three  years,  he  never,  in  the  least,  suspected  any  malforma- 
tion. She  never  had  been  subjected  to  any  operation." 
{Journal  Universel  et  Hthdomadaire  de  Medecine,  etc.  tome 
XII.,  p.  167.    Faris:  Octobre,  1833.) 

Case  CCIT. — Switzer  mentions  the  case  of  a  public  girl 
whom  he  knew,  who  had  a  congenital  imperforate  anus,  and 
in  whom  the  rectum  opened  into  the  vagina.  This  girl 
informed  him  that  she  suffered  no  pain  in  passing  the  fneces, 
or  was  in  the  least  troubled  if  she  washed  herself  well  with  a 
sponge  after  each  evacuation.  If  her  words  are  to  be  believed, 
says  Switzer,  she  had  numerous  lovers.  {Annotationes  in  Co- 
lotomiam^p.l'i).     IlafnicB :  1826.) 

Case  CCIH.— On  the  12th  of  October,  1857,  C.  G.  Page, 
M.D.,  read  to  the  "  Boston  Society  for  Medical  Improve- 
ment^'''' the  following  very  interesting  account  of  a  case  of  im- 
perforate anus,  with  the  rectum  terminating  in  the  vagina. 
Tlie  case  was  that  of  Dr.  S.  F.  Ainsworth. 

"  Mrs.  K was  delivered  of  a  female  child,  mature  and 

of  average  size,  early  on  the  morning  of  Monday,  July  20th, 
1857.  On  examination,  two  openings  w^ere  found  in  the 
vagina,  one  occupying  the  place  of  the  urethra,  the  other  sit- 
uated between  the  internal  labia  and  surrounded  by  a  small 
red  tumor,  the  size  and  shape  of  a  common  bean.  Both  these 
openings  barely  admitted  a  common  probe,  and  from  both, 
while  under  examination,  a  small  quantity  of  yellow  meco- 
nium and  urine  was  expelled.  TheTe  was  no  external  trace 
of  the  anus,  the  skin  over  the  entire  perina^um  being  smooth, 
and  the  raphe  extending  to  the  coccyx.  At  each  expulsion 
of  the  meconium  or  in-ine  by  the  vagina,  a  slight  motion  was 
observed  in  the  perinasum,  as  if  some  fibres  of  the  levator  ani 
were  inserted  into  the  fascia.  On  exploring  the  openings  in 
the  vagina,  it  was  found  that  a  probe  carried  upward  close  to 
the  pubis  passed  into  the  bladder,  and  could  be  felt  on  the 
abdomen  ;  but  directed  backward  and  upward,  it  passed  in 
half  its  length  and  then  encountered  a  firm  body  which  was 
supposed  to  be  the  upper  part  of  the  sacrum.  When  passed 
downward,  the  point  could  be  carried  a  few  lines  below  the 
orifice  and  indistinctly  felt  in  the  perinjeum.  The  child  being 
quiet  and  apparently  liealthy,  it  was  decided  to  cut  down  on 


THE   SIXTH    SPECIES   OF   MALI'OKMATION.  275 

the  pcrinn3nm,  and,  if  possible,  bring  down  the  rectum.  On 
Tuesday,  assisted  by  Drs.  C.  (r.  Page  and  C.  II.  Stetbuan,  the 
operation  was  commenced  by  introducing  a  probe  into  the 
lower  opening  in  the  vagina,  and  passinf^  it  downward  as  far 
as  possible.  An  incision  was  then  matle  along  the  raphe  of 
the  perinroum,  and  continued  in  the  track  of  the  rectum 
about  an  inch  and  a  half;  the  point  of  the  ])robe  M'as  then 
distinctly  felt,  the  tissues  wefe  carefully  separated  from  the 
cul-de  sac,  and  the  intestine  easily  drawn  down  to  the  exter- 
nal opening,  where  it  was  laid  open,  the  serous  surface 
everted,  and  confined  by  sutures  to  the  edges  of  the  extermJ 
w^ound.  A  quantity  of  flatus  escaped  at  the  moment  of  open- 
ing the  intestine.  A  small  tent  was  placed  in  the  wound,  a 
wet  compress  on  the  perinreum,  and  a  T-bandage  a])])lied. 
The  patient,  until  the  following  Sunday,  w^as  attended  by  i)r. 
Page.  During  that  time,  the  child  did  well.  On  visiting 
the  child  on  Sunday,  the  wound  was  looking  w^elL  The 
nurse,  for  the  first  time  stated  that  there  had  been,  since  the 
birth,  intervals  of  great  distress  of  breathing,  accompanied 
by  a  purple  discoloration  of  the  face,  neck,  lips  and  ears. 
These  twrns  increased  in  frequency,  and  the  child  died  on 
Tuesday,  having  lived  eight  days. 

"  The  following  is  the  account  of  the  autopsy  : 
"  The  heart  was  found  malformed,  there  being  but  one  ven- 
tricle into  which  the  aorta  opened  directly  at  its  summit ;  the 
only  auricle  was  situated  on  the  right  posterior  aspect,  com- 
municating obliquely  with  the  ventricle.  The  pulmonary 
artery  was  very  small,  given  off  below  the  point  where  the 
aorta  enters  the  heart,  and  on  the  left  side  passing  upward 
and  backward  and  bifurcating  behind  the  aorta.  An  imper- 
fect valve  projected  into  the  ventricle,  attached  by  two  short 
and  firm  columnse  carnese,  and  by  two  slight  cordae  tendinee 
to  the  upper  and  lower  left  sides.  The  pulmonary  veins 
opened  into  the  auricle.  The  rectum  terminated  in  a  cul-de- 
sac  about  an  inch  and  a  quarter€rom  the  perinseum,  and  com- 
municated with  the  vagina  from  its  upper  borders.  The 
uterus  was  bifid.  Ko  other  abnormal  appearances  were 
observed."  {Boston  Medical  and  Surgical  Jommal.  Vol. 
LVIL,p.22>^.     Boston:  1S51.) 


(4.)  Case  in  which  the  Becttim,  together  u'ith  the    Urethra 
and  Vagina^  terminated  in  a  Cloaca  hi  the  Perinmum. 

Case  CCIV. — ^The  following  case,  reported  by  M.  Saviard, 
is  the  only  one  on  record  as  far  as  my  reading  extends,  in 


276  THE    SIXTH    SPECIES    OF   MALFORMATION. 

which  this  extraordinary  anomaly  was  observed  in  the  human 
enbject. 

"  On  tlie  6th  of  January,  1692,  a  woman  was  delivered  of 
a  child  at  the  Hotel  Dleu,  in  Paris,  which  M' as  very  defective 
in  its  conformation,  both  internally  and  externally.  This 
child  having  only  lived  a  few  days,  I  carried  its  body  to  my 
room  to  examine  it  with  M.  de  Verney,  who  had  desired  me 
to  show  him  all  the  subjects  that  were  remarkable. 

"  The  hands  were  alike  externally,  down  to  the  knuckles, 
very  even  on  the  outside,  and  on  the  inside  such  folds  as  are 
common ;  there  were  no  fingers  at  the  extremity,  but  they 
terminated  in  a  large  lump ;  its  feet  were  like  the  hands, 
without  toes,  and  terminated  in  the  samg  manner. 

"  We  discovered  by  the  dissection  of  the  extremities,  that 
the  bones  of  the  carpus  and  metacarpus,  of  the  tarsus  and 
metatarsus,  were  complete  in  number  and  order ;  the  whole 
difference  consisted  in  this,  that  it  was  observable  there 
appeared  at  the  end  of  each  bone  of  the  metacarpus  and 
metatarsus,  a  small  elongation  that  seemed  to  be  disposed  to 
form  the  phalanx  of  a  finger  or  a  toe,  but  it  seemed  as  though 
the  formation  was  incomplete  for  want  of  matt  er. 

"  Tliere  was  nothing  extraordinary  in  the  structure  of  the 
thorax ;  but  when  we  came  to  examine  the  remainder  of  the 
umbilical  vessels,  we  observed,  that  beside  the  umbilical  vein, 
tliere  was  only  one  artery  instead  of  two,  which  are  branches 
of  the  iliac  or  hypogastric,  and  that  this  artery  was  formed 
from  the  trunk  of  that  artery  which  ought  to  have  produced 
the  left  iliac.  When  I  penetrated  into  the  cavity  of  the  abdo- 
men we  observed  the  capsulm  atrabilares  thrice  their  natural 
dimension  and  their  vessels  of  the  ordinary  magnitude.  At 
length,  not  finding  in  the  regio  lumbaris,  either  on  the  right 
or  left  side,  neither  kidneys,  emulgent  vessels  nor  ureters,  we 
began  to  doubt  whether  the  capsulfe  atrabilares,  being  of  un- 
common size,  had  not  supplied  the  defect  of  those  organs  that 
were  wanting ;  which  induced  us  to  examine  carefully  whether 
these  capsulae  had  no  excretory  ducts  that  might  serve  for  that 
purpose.  Meeting  with  no  success  in  this  enquiry  we  prose- 
cuted our  dissection  to  a  tumour  upon  the  os  sacrum,  at  the 
place  where  it  begins  to  be  curved  in  order  to  form  the^;«Zt'/.9 
of  the  hypogastrium.  Having  opened  the  membrane  covering 
this  tumour  or  protuberance,  we  perceived  the  two  kidneys  at 
a  quarter  of  an  inch  distance  from  each  other,  but  fastened 
together,  notwithstanding,  by  means  of  a  small  ureter  proceed- 
ing from  the  left  canal ;  and  this  common  canal  discharged 
itself  into  a  large  Hole^  which  we  call  the  Cystis  Communis. 

After  we  had  examined  the  irregular  disposition  of  those 


TlIK    SIX'lII    SPKCIKS    OF    MALKOIIMATION".  277 

oi-o;ans  mentioned,  we  endeavored  to  discover  the  sex  (A'  tliis 
ijifunt,  which  lind  no  ;ip}»areiit  marks  of  either  externally,  by 
which  a  male  could  be  distino-uishcd  from  a  female.  To  this 
end  we  made  nse  of  a  blow-pipe,  and  blew  into  tlie  ci/.siis 
roimmmis,  whose  aperture  was  the  only  one  external.  Tlie 
blow-pipe  introduced  into  this  ef/si/6',  aitbrded  us  tlie  oj)por- 
tuiuty  of  observing  the  inflation  of  those  two  small  canals, 
which  were  perceived  to  rise  above  a  Anger's  breadth,  so  that 
l)ursuing  this  inflation,  we  found  two  small  wombs,  each  of 
them  having  a  spermatic  vein  and  artery  distributed  on  their 
proper  side  to  a  small  testicle,  which  according  to  custom,  was 
lixed  to  the  lif/amcntiun  latum.  These  two  wombs  had  each 
their  ligamenta  lata  and  rotimda.,  near  their  trunks  and  bor- 
ders, their  vasa  dtfereniia^  and  a  short  vagina ;  nevertheless  the 
right,  somewhat  longer  than  the  left,  emptied  itself  a  little 
lower  into  the  cysth  communis,  and  the  small  left  vagina  was 
pierced  to  receive  what  was  discharged  from  the  common  canal 
of  the  uretlu-a,  which  evacuated  the  serum  separated  by  the 
kidneys  into  that  cystis.,  and  this,  to  speak  truth,  was  only  the 
extremity  of  the  rectimi  a  little  dilated. 

"  It  is  very  probable  by  the  description  of  these  organs  that 
if  this  child  had  lived  to  be  adult,  it  would  have  been  incapa- 
ble of  generation,  from  the  mixture  of  the  seed  with  the  ster- 
coral and  urinary  excrements.  i)esides,'both  these  excrements 
would  have  had  an  involuntary  exit."  {Ojpus  citatum.,  Ohser- 
V  at  ion,  XGIY^ 

Tlie  ffllowing  cases  all  belong  to  this  the  sixth  species,  and 
should  be  so  classed.  Their  history  and  description,  for  obvi- 
ous reasons,  will  be  given  in  the  chapter  on  Abdominal  Artifi- 
cial Anus. — [  Vide  Chapter  XI.^ 

Cases    CCLYII— CCLIX— C  CLXII— CCLXX  V 
— CCLXXIX— CCLXXXm. 


CH^I>TER  VIII. 

THE  SEVENTH  SPECffiS  OF  MALFOEMATION. 

SECTION     I. 

DESCRIPTION. 

In  this  singular  species  of  malformation,  the  rectum,  together 
with  the  anus,  is  usually  normal,  hut  either  the  ureters,  the 
vagina  or  the  uterus,  may  terminate  in  it,  hy  an  abnormal 
orifice,  and  the  urine  and  the  menstrual  fluid  be  discharged 
by  this  unnatural  route. 

In  these  instances  there  often  exist  other  malformatioDS 
at  the  same  time — such  as  the  absence  of  the  bladder,  the 
absence  of  the  urethra  in  the  female. 

Fortunately  cases  of  this  deplorable  infirmity  are  compar- 
atively rare. 

When  the  ureters  terminate  in  the  rectum,  they  generally 
enter  at  a  short  distance  below  the  line  of  reflection  of  the 
peritonseum.  (Oberteufer.  Nexies  Archiv.  de  Sta?'7c,  tome 
II.) 

"When  the  vagina  terminates  in  the  rectum,  the  urethra 
usually  occupies  its  natural  position,  and  the  menstrual 
evacuation  passes  out  by  the  anus.  What  is  very  remarkable 
in  such  cases,  is  the  fact  that  through  the  anal  orifice  impreg- 
nation has  been  known  to  have  taken  place,  and  that  even 
parturition  has  been  safely  effected  by  more  or  less  laceration, 
however,  of  the  perinjeum.  Barbout  says  that  he  delivered 
two  women  per  rectum.  Professor  Rossi  mentions  a  singular 
case.      [Vide   Cases  CCXII—CCXIII—CCXVIII]      M. 

Louis  also  mentions  a  highlv  interesting  instance  of  the  same 

(278) 


THE    SEVENTH    SPECIES    OF   MALKOUMATION.  279 

diameter.  [Vide  Case  CCXIV.]  Tliis  famous  case  of  M. 
Louis  was  made  the  subject  of  bis  celebrated  thesis,  in  which 
lie  established  the  fact,  not  only  of  the  possibility  of  concep- 
tion, but  also  of  a  successful  accouchement  in  such  cases  :  (De 
paituim  externaram  generatioiii  inserventium  in  mulieribus, 
naturali,  vitiosa,  et  morbosa  dispositione.  Theses  AnatomiccB 
Chu'Hrgic€B^  Paris :  1753.) 

This  thesis  of  M.  Louis  was  delivered  to  the  schools  of 
surgery  over  which  he  presided,  aud  caused  him  to  be  prose- 
cuted by  the  Parliament  of  Paris  ;  and  the  Doctors  of  the 
Sorboiine  interdicted  him,  for  addressing  to  the  casuists  the 
following  question  : — "  In  uxore^  sio  disposita,  tiii  fas  sit  • 
vel  non  f  Judicent  theologi  morale?,  V  [Let  moral  theologians 
judge,  whether  in  a  wife  thus  formed,  the  action  was  lawful 
or  not.]  » 

The  Pope,  however,  being  much  more  philosophic  than 
the  Parliament  or  the  Sorbonne,  gave  M.  Louis  absolution, 
and  his  thesis  was  published  in  1754. 

The  uterus  also  has  been  known  to  terminate  in  the 
rectum.      Yallesnieri   describes   such   a   case.     [  Yide    Case 

ccxxi.-] 

In  such  a  case  as  Yallesnieri  mentions,  as  in  those  already 
named,  coitus  per  anura,  would  doubtless  also,  be  followed  by 
conception. 

This  species  of  congenital  malformation  does  not  necessa- 
rily result  in  early  death,  as  we  perceive  from  the  cases 
reported,  yet  the  unfortunate  victims  of  any  one  of  its 
varieties,  are  rendered  deplorably  miserable  for  life. 


SECTION    II. 
THE    TREATMENT. 


The  powers  of  nature  and  of  art  combined,  seem  altogether 
inadequate  to  remedy  so  serious  a  defect,  as  is  presented  by 


280  THE    SEVENTH    SPECIES    OF   MALFORMATION. 

some,  if  not  all  tlie  cases  of  this  species  of  congenital  malfor- 
mation. Althongli  surgery  may  be  out  of  the  question  in 
these  cases,  nevertlieless,  they  are  still  highly  interesting  in 
a  pbysiologico-pathological  point  of  view. 


SECTION    III. 
CASES   AND  REMARKS. 

(1.)  Cases  «Vi  lohich  the  Ureters  Terrtiinated  in  the  Rectum. 

Cases  CCV.— CCYL—  CCVII.—  CCYIir.—CCIX.— Cam- 
per mentions  five  cases  in  M'hich  the  ureters  terminated  in 
the  rectum,  the  bladder  being  absent  in  each ;  one  of  M"hich 
was  that  of  a  female.  {^Memoires  sur  les  Svjets proposes  jyour 
les  Prix  de  V Acaderaie  de  Chirurgie.  tome  V.  p.  9. 
Paris:  1775.) 

Case  CCX. — Klein  speaks  of  a  case  in  which  the  ureters 
terminated  in  the  rectum.  {Rachit  congenit.  Hova  Acta 
Acadcmie  Naturw  Curiosuni.     Ann.  I.   Observ.  38.) 

Case  CCXI. — Richardson  relates  the  case  of  a  Yorkshire 
boy  seventeen  years  old,  in  whom  the  nreters  terminated  in 
the  rectum,  and  who  never  voided  his  urine  but  by  the  anus. 
Doubtless,  in  this  case,  the  bladder  was  wanting.  The  contin- 
ued passage  of  the  urine  through  the  anus,  gave  rise  to  much 
irritation  and  diarrhoea,  which  did  not,  however,  impair  his 
general  health.  {Philosophical  Transactions  of  the  Royal 
Society  of  London.       Vol.    VII.) 

(2)  Cases  in  which  the  Vagina  Terminated  in  the  Rectum. 

Cases  CCXII. — CCXIII. — Barbout  mentions  two  instances 
of  delivery  by  the  rectum,  which  occurred  in  his  practice  be- 
tween the  years  1739  and  1775.  In  both  cases  the  catamenia 
flowed  by  the  anus,  there  being  no  vulva.  In  one  of  these  the 
mother  of  the  woman  contended  that  her  daughter  could  not 
become  pregnant,  because  the  lochia  was  passed  by  the  anus. 
In  one  case  the  perinseum  was  torn  ;  in  tlie  other  it  was  cut 
with  a  bistoury.  {Suite  da  Cours  d'Accouchemens.  tome  II. 
2?.  od.     Paris:  1775.) 


Till':   SEVENTH    SPECIES    OF    iMALF'OUMATION.  281 

Cask  CCXIV. — M.  Louis  relates  the  foUowiiifij  hii>;]ily  iiitcr- 
estiiif:;  case  of  a  youiii;;  lady  m'Iio  had  a  coiiifciiital  iinjx'rtora- 
tioii  of  the  external  ori;-ans  of  generation.  This  girl  menstru- 
ated per  anuni.  She  was  solicited  in  marriage  by  a  y<»ung 
man  to  whom  she  was  much  attached.  After  much  resistance 
she  confessed  to  him  the  secret.  In  the  height  of  his  passion, 
he  besc»ught  her  to  allow  him  to  unite  in  the  only  way  which 
was  practicable.  She  consented  to  everything,  and  became 
pregnant.  The  delivery  of  an  infant  took  place  at  the  proper 
time,  causing  a  la(;eration  of  the  sphincter  ani.  {llieses  Ana- 
toiiiicoi  Chh'uiylcm.     Paris:  1753.) 

Case  CCXV. — Portal  speaks  of  a  girl,  who  having  no  vulva, 
the  vagina  o]->ened  into  the  rectum,  through  which  medium 
she  passetl  her  catamenia.  She  became  pregnant,  and  at  the 
moment  of  delivery,  the  perina^um  became  so  distended  that 
it  was  ruptured.  {Precis  de  Chirurgie  Pratique,  tome  II. 
p.  745.     Paris:  176S.) 

Case  CCXVI. — Engel  mentions  a  case  of  a  woman  who 
having  no  vulva,  the  vagina  opened  into  the  rectum.  [Dis- 
sertatio  de  Utero  dcjicieiite.  apud.  Schlegel.  tome  I.  p.  259.) 

Case  CCXVII. — M.  Orfila  mentions  a  similar  case  to  that 
of  Engel.     {Medeoine  Legale,     tome  I. p.  IhO.   Paris:  1821.) 

Case  CCXVIII. — Professor  Rossi  has  recorded  a  curious 
case  of  a  woman  in  whom  there  was  complete  absence  of  the 
vulva,  yet  notwithstanding,  pregnancy  and  natural  delivery 
took  place.  This  woman  was  married,  but  as  the  malform- 
ation of  the  genital  organs  was  known,  it  was  not  suspected 
that  pregnancy  could  have  occurred,  and.  consequently,  that 
the  pains  she  felt  at  the  approach  of  labor,  were  supposed  by 
her  friends  to  be  arising  from  an  attack  of  colic. 

Upon  examination,  it  was  ascertained  that  there  was  no 
trace  of  the  external  organs  of  generation.  Tlie  pubis  was 
void  of  hair.  It  was  thought  that  the  pains  might  result  from 
retention  of  the  menses.  M.  Possi  examined  the  rectum,  and 
determined  on  making  an  incision  of  three  fingers'  breadth 
in  length  in  the  natural  direction  of  the  vulva  and  vagina. 
He  was  much  astonished  at  feeling  with  his  finger,  which  he 
introduced  into  the  wound,  the  membranous  sac  containing 
the  waters  laying  over  the  opening  of  the  neck  of  the  uterus. 
The  membranes  ruptured  after  frecpient  and  violent  pains. 
The  head  of  the  fa?tus  presented,  and  the  labor  was  completed 
by  the  natural  efforts.     The  child  lived  six  hours. — The  incis- 


282  THE   SEVENTH    SPECIES   OF   MALFORMATION. 

ion  which  had  been  made  in  the  direction  of  the  vagina  was 
kept  oj^en  by  means  of  a  tube  which  was  distended  with  air 
after  its  introduction,  so  that  in  future  the  canal  might  be  of 
Bufhcient  dimensions  to  receive  the  penis.  That  this  intention 
was  accomplislied,  is  proved  from  the  fact  of  tlie  woman  liav- 
ing  become  pregnant  a  second  time,  and  in  two  years  after- 
wards she  was  delivered  by  this  new  passage.  The  inform- 
ation which  was  gained  from  her  husband  led  to  a  more  care- 
ful examination  of  the  rectum,  and  an  orifice  was  found  within 
the  anus,  wliich  would  only  admit  a  siixall  probe.  This  orifice 
communicated  Math  the  artificial  canal  which  had  been  made 
by  the  surgeon,  and  was  no  doubt  the  channel  by  which 
impregnation  had  been  efl:ected. 

The  reflections  which  were  suggested  to  M.  Rossi  upon 
considering  this  case,  are  not  devoid  of  interest.  Such  was  the 
malformation  of  the  parts,  that  the  os  uteri  had  no  other 
external  communication  but  by  the  small  hole  within  the 
anus.  This  aperture  was  so  small  that  it  would  not  have  been 
seen,  had  the  parts  not  been  very  carefully  examined.  It  did 
not  pass  in  the  direction  of  the  opening  of  the  cervix  uteri, 
but  formed  an  angle  with  that  part.  It  is  difficult,  therefore, 
to  conceive  that  the  male  semen  could  possibly  have  pene- 
trated the  uterus.  He  therefore  imagines  that  "  m  quodam 
spiritu,  quddam.  aura,  exGiijus  'prcBsentla  organorwm  genita- 
lium  imilierum  vis  peculiaris  modo  ahsoj'hens  excttaUirT 
{Hlstoire  de  la  Societe  de  Medicine  de  Montjpellier,  tome  I^jj. 
39.) 

Cases  CCXIX — CCXX. — A  case  of  absence  of  the  vulva, 
with  the  vagina  terminating  in  the  rectum,  is  recorded  in  the 
"  Meinoires  de  Berlin^''  for  the  year  1774.  A  similar  case  in 
every  respect  is  found  recorded  in  the  "  Journal  des  Savants^^ 
for  the  year  1777. 


(3.)  Case  in  which  the  Uterus  Terminated  in  the  Rectum. 

Case  CCXXI. — ^Yallesnieri  dissected  a  female  in  wliom 
were  found  two  uteri ;  the  orifice  of  one  opened  into  the  va- 
gina, whilst  that  of  the  other  into  the  rectum.  M.  Fournier 
says,  in  relation  to  this  case,  that  there  is  no  doubt  but  that 
coitus  per  ajium  would  liave  been  followed  by  conception. 
He  founds  this  opinion  upon  the  case  related  by  M,  Louis. 
{Dictionnaire  des  Sciences  Medicates  de  Paris,  tome  IV.) 


CHAPTER    IX. 

THE  EIGHTH  SPECIES  OF  MALFORMATION. 

SECTION    I. 

DESCRIPTION. 

This  species  of  congenital  malformation  is  characterized  by 
the  entire  absence  of  the  rectum,  or  by  the  comj)lete  oblitera- 
tion of  its  whole  cavity,  and  constitutes  one  of  the  most  seri- 
ous vices  of  conformation,  pertaining  to  these  parts,  infallibly 
leading  to  death  in  a  few  days  unless  the  patient  is  relieved 
by  surgery.  In  these  instances  the  colon  generally  ends  in  a 
cul-de-sac,  and  either  floats  unattached  in  the  abdominal  cav- 
ity, is  suspended  in  the  pelvic  cavity,  or  fastened  down  to  the 
top  of  the  sacrum.  The  absent  rectum,  in  case  of  complete 
obliteration,  which  occasionally  though  rarely  occurs,  is  re- 
presented by  a  fibro-ligamentous  cord  attached  to  the  blind 
end  of  the  colon,  and  sometimes  passing  down  along  the  sac- 
rum and  becoming  blended  with  the  cellular  tissue  behind 
the  prostate  gland  and  the  neck  of  the  bladder.  The  pelvis 
in  these  cases  is  sometimes  abnormally  small  and  contracted, 
and  there  is  generally  no  sign  whatever  of  a  normal  aims  pre- 
sent, yet  occasionally  a  preternatural  anus  does  exist. 

This  is  comparatively  a  very  rare  deformity,  being  by  no 
means  as  common  as  that  in  which  a  portion  only  of  the  rec- 
tum is  wanting.  Some  authors,  however,  confound  these 
cases ;  they  arrange  under  the  head,  ahsence  of  the  rectum, 

cases  in  which  there  is  only  a  partial  absence  of  the  rectum, 

(283) 


284  THE   EIGHTH    SPECIES   OF   MALFOEMATION. 

thus  making  no  distinction  whether  the  rectum  is  partially  or 
wholly  wanting. 

This  species  of  malformation  is  usually  attended  by  some 
other  deformity,  especially  by  a  contraction  of  the  pelvis. 
MM.  Martin,  L'Eveille,  and  Meckel  report  such  cases. 
[Vide  Cases  CCXXXY1I^-CCXXXYIII—CCXXXIX:\ 

These  authors  have  made  the  important  observation,  that 
in  cases  in  which  the  rectum  is  wholly  wanting,  the  pelvis  is 
usually  very  narrow,  and  that  the  nates  approximate  closely 
to  each  other.  This  is  doubtless  the  result  of  an  early  arrest 
of  development  of  the  pelvis  in  its  evolution. 

As  there  is  no  positive  or  pathognomonic  sign  by  which  the 
absence  of  the  rectum  may  certainly  be  known,  we  can  only 
establish  our  diagnosis  in  the  usual  manner,  by  a  thorough 
exploration,  as  advised  in  the  fourth  chapter,  and  by  search- 
ing for,  and  endeavoring  to  reach  the  rectum  through  the 
perinaeum  with  the  knife.  Should  we  fail  thus  to  find  it,  we 
conclude  that  it  does  not  exist.  Some  surgeons  in  these  cases, 
recommend  making  an  exploratory  puncture  over  the  normal 
position  of  the  anus ;  when  the  rectum  or  some  portion  of  it  is 
present,  there  will  be  a  flow  of  meconium  follow  the  with- 
drawal of  the  instrument ;  when  the  rectum  is  absent,  no  issue 
of  meconium  will  follow  the  puncture.  This  proceeding, 
however,  is  too  hazardous  and  too  uncertain,  and  should  never 
be  adopted. 


SECTIONII. 

THE  TREATMENT. 

The  only  treatment  that  holds  out  any  prospect  of  success 
in  cases  in  which  the  rectum  is  wholly  absent,  is  the  creation 
of  an  abdominal  artificial  anus.  [  Vide  Chapter  on  Abdom- 
inal Artificial  anus.'} 


THK    I.IGIITII    SrECIEb   OF   MALFORMATION.  2S5 

M.  Amnssat,  I  tlihik  it  is,  wlio  asks  tlie  question — SliouM 
the  suri^eon,  in  searching  tor  tlie  rectum  through  the  perin- 
a3uni,  l';ii!  to  find  it,  hut  find  tlie  end  of  the  colon  or  some 
other  intestine,  should  he  bring  this  down  in  the  perinatal 
region  and  form  an  artificial  anus  there,  in  preference  to  one 
in  the  abdomen  ?  I  would  answer  3'es — provided  the  intes- 
tine met  with,  was  long  enough,  had  no  adhesions,  and  could 
be  brought  down  easily  without  violence  being  used. 


SECTION    III. 
CASES    AND     REMARKS. 

Case  CCXXII. — Binninger  saw  a  child  who  presented  no 
trace  of  an  anus,  and  the  attempt  to  reach  the  rectum 
through  the  perinseum  failed.  The  child  died  ten  days  after 
birth. 

At  the  autopsy  it  was  found  that  the  colon  terminated  in  a 
cul-de-sac,  and  was  further  on,  changed  into  a  slender  cord. 
The  rectum  was  completely  absent.  {Ohsero.  et  Curat,  M<i(J. 
ccntur.  II.  Olserv.  ^l,p.  222,  Ilontbdg :  1673.  Also,  Dlctlon- 
naire  des  Sciences  Medicates,  tome  XXIV.  jp.  129.) 

Case  CCXXIII.— Bonet  records  the  case  of  a  child  in 
whom  no  rectum  existed.  {Sepulcretum  Anatomicum.  Sect. 
XVII) 

Case  OCXXIV. — Morgagni  records  the  case  of  a  child  in 
whom  the  entire  rectum  was  "  solid  like  a  ropeJ^  {Ojym 
citatmn,  lih.  Ill  Epist.  XXXII.  Art  3.  et  5.) 

Cases  CCXXV — CCXXVI. — Ruysch  mentions  having 
seen  two  new-born  children,  in  whom  there  was  no  trace 
whatever  either  of  an  anus  or  a  rectum.  No  operation  was 
performed  and  death  was  the  result.  {Adversaria  Anatorii- 
ica,  decad.  11.  c.  10.  p.  43.) 

Case  CCXXVII. — Beauregard  relates  the  case  of  a  child 
in  whom  the  colon  terminated  in  a  cul-de-sac  and  the  rectum 
was  wanting.  {Backer  Journal  de  Medicine,  Janvier,  1786. 
p.  90.) 


286  THE   EIGHTH    SPECIES    OF   MALFOEAIATION, 

^  Cases  CCXXYIII— CCXXIX.— Meiy  relates  the  curious 
circumstance  of  two  male  infants  {twins)  whom  he  saw,  and 
who  were  destitute  of  the  anus  and  rectum ;  and  in  both  of 
whom  the  colon  terminated  at  the  umbilicus  in  a  nipple-like 
projection,  in  the  centre  of  which  was  an  opening  a  line 
and  a  half  in  diameter,  through  which  the  faeces  passed. 
Both  cases  terminated  fatallj^  no  operation  having  been  per- 
formed. {Historu  de  VAcacUjnie  Royale  des  Sciences,  Aiinee 
1700.^.  40.) 

Case  CCXXX. — Henkel  relates  a  case  in  which  no  rectum 
existed.     {Mem.  Med.  Clvirug.  Amnerkungen,  11.  17T2.) 

Case  CCXXXI. — Estero  mentions  a  case  in  which  the  rec- 
tum was  absent.     {Listit.  Chirurg.  tome  11.  Sec.  V.  cap.  163. 

m.  1.) 

Case  CCXXXII. — Bonn  reports  an  instance  in  which 
there  was  a  complete  absence  of  the  rectum.  (Papendorf. 
OjMs  citatum.) 

Case  CCXXXIII. — Ludov^icus  gives  an  instance  of  a  child 
in  whom  no  rectum  existed.  {Miscellanea  curiosa  sive 
ephem.  acad  natur  curiosor.  ami.  III.  decur.  I.  ohserv.  257.) 

Case  CCXXXI V. — Huber  reports  a  case  in  which  the 
rectum  was  wanting. — {Acta  Physco-Medica.  tome  VII, 
Ohserv.  24:.  _p.  64:.) 

Case  CCXXXY. — Matani  cites  the  case  ot  a  child  in 
whom  the  rectum  was  wanting.  {Orteshi  Giornal  di  Medi- 
cini.  tome  III.  p.  250.  Padoue.) 

Case  CCXXXVI. — Mr.  Jamieson,  surgeon  in  Kelso,  relates 
the  following  interesting  case  of  imperforate  anus,  and  ab- 
sence of  the  rectum. 

"Some  years  ago,  Mrs.  Hannah,  midwife  in  this  town,  was 
called  to  one  Mrs.  Stevenson,  in  Plowland,  five  miles  distant 
from  this  place,  whom  she  delivered  of  twins,  the  one  female, 
the  other  male ;  and  discovering  in  the  latter  no  appearance 
of  an  anus,  came  home,  and  sent  me  to  see  the  child,  whom  1 
found  otherwise  sprightly,  and  seemingly  in  perfect  health, 
but  not  the  least  vestige  of  an  anus  to  be  seen  or  felt,  but 
equally  firm  and  solid  from  the  coccyx  to  the  scrotum  :  where- 
upon I  told  the  grandmother,  who  only  was  acquainted  there- 
with by  the  midwife,  that  it  was  preternatural,  and  that, 


THE   EIGHTH    SPECIES    OF   MALEORMATION.  287 

though  I  liad  twice  seen  the  anus  covered  by  a  membraiie, 
which  was  easily  cured,  I  conhl  not  projiose  to  do  the  like  in 
this  ;  but,  if  she  pleased,  I  should  try  to  reach  the  gut  by  in- 
cision, which  she,  with  the  mother's  consent,  fondly  agreed 
to:  whereupon  I  made  an  incision  pretty  deep  in  the  most 
reasonable  })art,  then  introduced  my  little  linger  into  the 
wound,  to  tind  the  gut,  but  in  vain. 

"  1  afterwards  tried  the  trocar,  which  penetrated,  but  nothing 
followed  but  some  gutts  of  blood  ;  so  was  obliged  to  leave  the 
patient  without  |)rospect  of  further  help  from  me,  only  desired, 
that  when  he  died,  I  might  be  allowed  to  open  the  body, 
which  1  did  next  day. 

'•  Upon  opening  the  child,  I  saw  the  rectum  entirely  wanting, 
and  the  colon  was  a  perfect  intestinam  caecum^  suspended 
loosely  in  the  abdomen,  and  full  of  meconium  ;  all  the  other 
parts  being  in  a  natural  state."  {Edinburgh  31edical  Essays 
and  Ohseroations,   Vol  IV.,  Art.  XXXIII,]^.  354,  1771.) 

Case  CCXXXYII. — Martin  de  Lyon  saw  a  case  in  which 
the  rectum  was  entirely  wanting.  In  this  instance  the  tuber- 
osities of  the  ischia  approached  so  near  each  other,  that  the 
pelvis  was  almost  closed.  {Meriioires  de  la  Societe  de  Sante 
de  Lyon,  tome  I,  p.  185.) 

Case  CCXXXVIII. — Meckel  reports  a  case  in  Mhich  tlie 
rectum  was  absent,  and  the  pelvis  quite  small  and  contracted. 
{MeiVs  Archivfur  die  Physiologic,  Band  IX.,  Heft  I.) 

Case  CCXXXIX. — M.  Leveille  reports  the  case  of  a  child 
in  whom  the  rectum  was  entirely  wanting,  and  the  pelvis  so 
small  and  contracted  that  it  presented  quite  a  deformity. 
{y)Ki^-A\\\\,  Journal  de  Chirurgie,  tome  IV.,  sur  V imperfora' 
tlon  d\mus.) 

Case  CCXL. — Giering  mentions  an  instance  of  a  child  in 
whom  no  rectum  existed.  {8el  Med.  Francqf.  tome  IV., 
p.  137.) 

Case  CCXLI. — Fitteau  reports  the  case  of  an  infant  in 
whom  the  rectum  was  entirely  absent.  (Sedillot,  liecueil 
Periodiqiie.  tome  II.,  p.  101.) 

•  Case  CCXLII. — Carvenon  cites  the  case  of  a  child  in  whom 
the  rectum  was  w^auting.  (Sedillot,  Eeoaeil  Periodique.  tome 
II.,  p.  36.) 


288  THE   EIGHTH    SPECIES    OF   MALFORMATION. 

Case  CCXLIII. — Oosterdyke  reports  the  case  of  an  infant 
ill  wliom  no  rectum  existed.     (Papeudorf.    Opus  citattiin.) 

Case  CCXLIY. — Fleisclimann  reports  tlie  case  of  a  male 
child  in  whom  both  the  anus  and  the  rectum  were  wanting, 
and  the  colon  terminated  in  a  cul-de-sac  and  hun^  looselj  in 
the  abdominal  cavity.  [  Vide  Plate  XIII,  Figure  l.J 
(2>«  Vitiis  Congenitis  Circa  Thoracem  et  Abdomen.  Tab. 
IV.  ErdargcB   1810.   Uo>, 

Case  CCXLV. — Otto  cites  the  case  of  an  infant  in  whom 
the  rectum  was  absent.  {PatJiologische  Anatomie.  Bres- 
lau:  1813.) 

Case  CCXLYI. — Dr.  Palmer  dissected  the  body  of  a  child 
in  whom  the  colon,  after  reaching  the  vicinity  of  the  left  kid- 
ney, began,  as  it  descended,  to  form  a  sigmoid  flexure,  but 
previously  to  its  arrival  at  the  concavity  of  the  left  ilium, 
made  a  sudden  turn  to  the  right,  and  crossing  the  psoas  mus- 
cle, reached  the  projection  of  the  sacrum,  where  it  terminated 
without  at  all  entering  the  ])elvis.  With  this  malformation 
was  combined  an  imperforate  meatus  urinarius  and  other  con- 
siderable deviations  of  the  genital  organs  from  their  natural 
structure.  [Medico-  Vhirurgical  Journal.  Vol.  I.  London  : 
1816.) 

The  case  of  Dr.  Palmer  was  that  of  a  female  child  who 
lived  four  days,  and  upon  whom  the  operation  for  imperforate 
anus  had  been  performed  without  success. 

Case  CCXLYII. — M.  Jacquemin  witnessed  the  following 
case  of  this  species  of  malformation : 

"  Several  years  since,  an  intant  was  brought  to  the  consult- 
ation of  M.  Dupuytren,  at  the  Hotel  Dieu,  who  had  not  yet 
passed  meconium.  A  bistoury  was  introduced  about  an  inch 
without  giving  issue  to  any  faecal  matter.  The  parents 
refusing  permission  to  make  any  further  attempt,  the  child 
shortly  died.  At  the  autopsy  it  was  discovered  that  there 
was  an  entire  absence  of  the  rectum."  {Revue  Medicals  de 
Paris.  Mai,  1835.  p.  286.) 

Case  CCXLYIIL— Mr.  AYcst  says  that  Mr.  Arnott  commu- 
nicated a  case  to  him  in  Avliich  the  child  lived  seven  weeks 
and  three  days,  the  rectum  being  entirely  absent  and  the 
colon  terminating  in  a  blind  sac,  and  floating  loosely  in  the 


TIIK    KIOIITII    SPKCIES   OF   MALFOKMATIOX.  28^ 

abdominal  cavity.    {Lectures  on  the  Diseases  of  Infancy  and 
Childhood,  p.  376.     Philadelphia  :  1854.) 

The  following  case  belongs  to  this  the  eighth  species,  aiul 
should  be  so  classed.  Its  history  and  description  will  be 
given  in  the  chapter  on  Abdomitial  Artifoial  Anus: 

Case  CCLXXIL 


19 


THE    NINTH    SPECIES    OF    MALFOKMATION. 
SECTION    I. 

DESCRIPTION. 

In  this  species  of  malformation  the  rectum  and  the  colon 
are  both  absent,  and  generally  some  other  portion  of  the 
intestinal  canal  terminates  externally  in  a  preternatural  anus, 
at  some  extraordinary  part  of  the  body — such  as  at  the 
umbilicus,  left  iliac  fossa,  the  lower  part  of  the  abdomen  just 
above  the  symphysis  pubis,  below  the  scapula,  and  at  the 
side  of  the  face,  as  it  has  been  known  to  have  occupied  each 
of  these  situations.     No  normal  anus  ever  exists. 

Writers  generally  in  describing  these  cases  remark  that  it 
is  the  rectum  which  terminates  externally  in  an  abnormal 
anus,  at  these  distant  and  unusual  situations  of  the  body. 
This  is,  however,  a  great  mistake,  for  in  these  instances  th« 
rectum  and  the  colon  are  absent ;  indeed,  the  rectum  when 
present  has  never  been  known  to  have  terminated  at  any  of 
these  extraordinary  points  of  the  body.  I  have  already 
shown,  in  the  sixth  chapter,  the  various  abnormal  situations 
at  which  the  rectum  has  been  known  to  have  terminated 
externally  in  a  preternatural  anus. 

This  species  of  malformation  is  but  seldom  met  with,  and  is 
usually  attended  by  other  aberrations  of  structure.  Tlie  preter- 
natural anus  or  faical  fistula  which  generally  attends  it,  is  a  most 
disgusting  infirmity,  and  unfortunately  one,  which  in  the  ma- 
jority of  cases,  can  be  but  little,  if  any,  benefited  by  a  surgical 

operation.     It  does  not,  however,  always  necessarily  at  once 

(290) 


THE   NINTH    SPECIES   OF   MALFORMATION.  291 

prove  mortal,  as  would  be  the  case  if  no  opening  at  all 
existed,  but  on  the  contrary  the  miserable  patients  have  been 
known  to  have  lived  for  months  and  for  years.  Happily  such 
cases  are  not  common. 

Sometimes  this  malformation  is  not  accompanied  by  an 
abnormal  anus,  and  then  it  is  truly  formidable,  there  being 
no  rectum,  no  colon,  and  no  outlet  whatever  for  the  passage 
of  the  excrementitious  matters. 

By  a  proper  exploration,  the  existence  or  non-existence  of 
the  colon,  can  be  very  easily  ascertained,  and  the  diagnosis 
established  accordingly. 


SECTION     II. 

THE  TREATMENT. 

"When  the  absence  of  the  rectum  and  the  colon  is  not 
accompanied  by  a  preternatural  anus,  the  case,  as  before 
observed,  is  desperate,  and  demands  immediate  treatment. 
Nothing  but  the  formation  of  an  abdominal  artificial  anus, 
either  in  the  caecum,  or  in  the  ileum,  holds  out  any  hope  of 
saving  the  life  of  the  patient. 

M.  Yoisin,  in  a  case  in  which  the  rectum  and  colon  were 
absent,  but  which  was  accompanied  by  an  abnormal  antis 
situated  in  the  hypogastrium,  established  an  artificial  anus  in 
the  abdomen,  according  to  the  method  of  Littre.  Instead, 
however,  of  opening  the  colon  as  he  thought,  which  in  this 
case  was  absent,  he  opened  the  ileum.     [  Vide  Case  CCLX.'] 

Should  the  abnormal  anus  which  usually  attends  this  mal- 
formation, or  this  absence  of  the  rectum  and  colon,  be  of  sirffi- 
cient  size  to  admit  of  an  adequate  discharge  of  fseces,  it  ought 
not  to  be  interfered  with.  Should  it  not  be  large  enough, 
eflforts  should  be  made  to  enlarge  it,  either  by  dilatation  or 
incision.     The  inconvenience  of  the  infirmity,  however,  shoul  d 


292  THE   NINTH    SPECIES    OF   MALFORMATION. 

always  be  preferred  to  an  uncertain  operation  wliich  might 
be  attended  with  more  or  less  danger,  and  should  only  be 
j^erformed  in  case  of  the  most  urgent  necessity.  As  1 
remarked  before,  in  a  large  number  of  these  cases,  surgery 
can  afford  no  aid,  so  far  as  the  preternatural  anus  is  concerned. 
In  all  such  cases,  therefore,  as  do  not  admit  of  a  surgical 
operation,  the  efforts  of  the  surgeon  should  be  directed  to  the 
use  of  palliative  measures  for  the  alleviation  of  the  suffer- 
ings of  the  patient,  and  for  rendering  him  less  offensive  to 
himself  and  others.  This  may  often  be  accomplished  by 
various  mechanical  contrivances. 


SECTION      III. 

CASES  AND  REMARKS. 

Case  CCXLIX. — 'M.  Littre  records  the  case  of  a  child  in 
whom  both  the  rectum  and  the  colon  were  absent.  In  this 
instance  the  ileum  opened  into  a  fleshy  pocket  the  size  of  a 
hen's  egg.  From  the  inferior  extremity  of  this  pocket  was 
a  canal  three  lines  long  and  tw'o  thick,  wliich  terminated  in  a 
circular  opening  a  line  and  a  half  in  diameter,  situated  just 
above  the  symphysis  pubis.  This  abnormal  opening  served 
the  child  as  an  anus.  Tliis  case  resulted  in  death,  no  opera- 
tion having  been  performed.  {Meinoire  de  V Academie  Royale 
des  Sciences  de  Paris.    Annee  1709.   p.  9.) 

Case  CCL. — M.  Petit  reported  to  the  Academy  of  Science, 
the  history,  in  the  case  of  a  child  who  had  neither  a  rectum 
nor  a  colon,  and  only  a  portion  of  the  cfficum.  In  this  case 
the  extremity  of  the  ileum  terminated  at  the  left  side  of  the 
has-ventre  in  an  abnormal  anus.  {Memoire  de  V Academie 
Royale  des  Sciences  de  Paris.    Annee  1716.   p.  89.) 

Case  CCLI. — An  extraordinary  case  is  related  by  Bils,  in 
w^hich  the  intestine  ascended  from  the  pelvis,  througli  tlie 
chest,  into  the  neck,  and  opened  on  the  face  by  a  very  small 
orifice.  {Specimina  Anatomica  et  Varia  Opuscula,  p.  10. 
Roterod:  1661.  4^o.) 


TIIK    NIMH    SrKCIES   OF   MALFORMATION.  293 

Cask  CCLII. — Dr.  l)Uslio  suj^s  tliat  Dinmorc  rnoitions  a 
remarkable  instance  of  jiu  iiifjuit  iu  Avliom  the  inferior  i)or- 
tion  of  the  abdomen  was  badly  (leveh.)i)ed.  In  this  case  some 
portion  of  the  intestinal  canal  tnrncMl  upward  and  opened 
niider  the  border  of  the  right  scapula,  (^Malformations^ 
Injuries  and  Diseases  of  the  Itectuin  and  Anus,  p.  46. 
JVew  York :  1837.) 

Case  CCLIII. — Professor  Samuel  D.  Gross,  of  the  Jefferson 
Medical  College,  dissected  a  fostus  in  which  both  the  rectum 
and  the  colon  were  wanting  ;  the  ileum  terminating  iu  a  capa- 
cious cul-de-sac  two  inches  and  a  half  in  length,  and  floating 
loosely  in  the  abdominal  cavitv.  {Pathological  Anatomy,  ]). 
628.     Pliiladel])hia :  1845.) 

Case  CCLIY. — The  following  case  of  imperforate  anus, 
M-itli  absence  of  the  rectum  and  colon,  is  given  by  Dr.  Loh- 
mann : 

"  The  author  was  called  to  a  child  who  had  been  born  five 
days,  and  who  up  to  that  time  had  passed  nothing  from  its 
bowels.  It  was  a  boy  of  mature  but  weak  development.  From 
the  account  of  the  mother,  vomiting  of  a  thickish  green  fluid 
had  occurred  several  times.  The  raphe  of  the  scrotum  was  con- 
tinued to  the  point  of  the  os  coccygis,  and  in  its  centre,  in  the 
place  where  the  anal  opening  is  usuallj'  found,  were  two 
strong  folds  of  skin  united  together.  The  abdomen  was  dis- 
tended, and  hard,  like  a  drum,  and  the  windings  of  the  small 
intestines  were  visible  below  the  skin.  A  puncture  an  inch 
deep  was  made  between  the  folds  with  a  lance,  and  kept  open 
with  charpie  ;  the  following  day  a  trocar  was  introduced,  to 
the  depth  of  two  inches.  It  seemed,  by  the  sensation  commu- 
nicated, that  the  instrument  had  been  pushed  into  an  empty 
space.  No  fa3ces  came  away,  and  the  child  died  on  the  day 
after,  the  seventh  from  birth. 

On  opening  the  body,  the  small  intestines  were  found  dis- 
tended with  gas,  and  in  many  places  filled  with  meconium,  and 
with  yellowish- colored  fseces.  The  colon  and  rectum  were 
altogether  absent.  The  ileum  went  to  the  place  where  tlie 
colon  should  have  comhienced,  and  there  terminated  in  a 
blind  sac,  distended  with  meconium.  There  was  no  commu- 
nication between  the  sac  and  the  neck  of  the  bladder.  The 
puncture  had  perforated  the  cavity  of  the  abdomen,  without 
reaching  the  blind  sac  described.  {Medicinisohe  Vercins 
Ziitung.    Berlin  :  1845.    iVo,  8.) 

The  following  case  belongs  to  this,  the  ninth  species,   and 


294 


THE   NINTH   SPECIES    OF   MALFORMATION. 


should  be  so  classed.      Its  history  and  description  will  be 
given  in  the  chapter  on  Ahdo7ninal  Artificial  Anus  : 

Case  CCLX. 


SECTION     IV. 
RECAPITULATION. 

The  following  table  will  exhibit  at  one  view  the  whole 
number  of  cases  of  congenital  malformation  of  the  rectum 
and  anus,  collected  from  various  sources  which  are  reported 
in  this  work.  It  will  give  the  number  of  each  species  ;  the 
number  treated  or  operated  on,  and  the  result ;  the  number 
not  operated  on,  and  the  result ;  and  the  number  of  those  cases 
in  which  neither  the  treatment  nor  the  result  are  reported. 
It  will  be  seen  that  it  comprises  by  far  the  largest  number  of 
cases  ever  before  published  in  a  single  work. 

TABLE. 


RESULT. 

o 

KESCLT. 

O 

Q 

is 

U 

r,  0 

o 

<l 

SPECIES. 

i 

H 

O 

« 

H 

tK 

0. 

0 

O 

0 

^S 

n 

o 

o 

U 

!5 

H 

ta 

D 

n 

n 

> 

O 

o 

0 

O 

d 

1.) 

u 

s 

b) 

& 

H 

Id 

O 

T? 

10 

8 

S 

1 

a. 

1 

z 

1 

12 

First  Species, 

Second   Species,       

16 
5« 

14 

49 

8 
23 

6 

26 

2 

1 

.... 

2 
1 

":V 

16 
53 

Third  Species, 

Fourth   Species, 

45 

25 

36 
14 

20 
43 

16 
1 

8 
1 

"i 

8 

1 
in 

45 

25 

Fifth  Species, 

Sixth  Species, 

85 
17 

27 

15 

12 

22 

11 

11 

36 

17 

85 
17 

Seventh  Species, 

Eighth  Species, 

?« 

5 

ft 

6 

6 

17 

28 

Ninth  Species, 

6 

1 

1 

1 

1 

4 

6 

287 

156 

87 

69 

42 

12 

30 

89 

287 

CHAPTER    XI. 

ABDOMINAL    AllTIFICIAL    ANUS. 
SECTION    I. 

GENERAL     REMARKS. 

The  term  aTtificial  anus^  from  having  been  indiscriminately 
extended  or  applied  to  the  preternatuial^  the  accidental^  or 
abnormal  anus,  has  occasioned  more  or  less  confusion  among 
surgical  authors.  This  term  is  strictly  applicable  only  to  such 
an  anus,  as  is  designedly  established  by  the  surgeon. 

The  first,  or  rude  idea  of  the  formation  of  an  artificial  anus, 
was  doubtless  the  result  of  suggestions  occasioned  by  having 
witnessed  and  contemplated  the  accidental  or  preternatural 
anus  ;  the  difiference,  however,  between  the  two,  compared 
as  an  affliction,  is  very  considerable,  the  latter  being  a  mere 
faecal  fistula,  located  in  the  small  intestine,  is  a  most  disgust- 
ing and  revolting  infirmity,  whereas  the  former,  approaching 
so  much  nearer  the  normal  anus  in  character,  is  far  less  often- 
sive,  and  consequently  quite  easy  to  tolerate. 

Two  operations  have  been  devised  and  proposed  by  sur- 
geons for  establishing  an  abdominal  artificial  anus,  for  the 
relief  of  insurmountable  obstruction  of  the  inferior  extremity 
of  the  intestinal  canal.  The  principles  upon  which  these 
operations  are  conducted  vary  considerably,  according  to  the 
difterent  localities  in  which  they  are  practised.  It  is  there- 
fore necessary  to  consider  them  separately  and  distinctly,  as 
performed  either  in  the  iliac  or  the  lumbar  region,  which  I  will 
presently  do.  [  Vide  Plate  XV.  Figs.  1,  2.] 
(295) 


296  ABDOMINAL   ARTIFICIAL   ANUS. 

Tlie  operation  for  abdominal  artificial  anus  should  by  no 
means  be  undertaken  until  the  surgeon  shall  have  first  failed 
to  recognize  the  end  of  the  rectum  through  the  perineum, 
and  after  having  exhausted  all  the  measures  for  disco verino- 
it  which  are  recommended  for  this  purpose.  Then,  and  not 
till  then,  should  he  consider  the  propriety  and  the  necessity 
of  forming  an  abdominal  artificial  anus,  which  at  best,  is  a 
poor  substitute  for  a  jDcrinseal  artificial  one. 

Some  very  able  and  distinguished  surgeons,  however,  have 
endeavored  by  very  plausible  reasoning,  to  establish  the  con- 
verse of  this  proposition,  namely,  the  formation  at  once  of 
the  abdominal  anus,  without  making  the  attempt  first,  to  form 
the  perinseal  one  ;  and  that  this  is  at  present  the  practice,  to 
a  considerable  extent,  in  some  parts  of  Europe.  M.  Amussat 
has  of  late  recommended  that  in  all  cases,  in  which  a  distinct 
fluctuation  cannot  be  detected,  through  the  integument  of  the 
perinseum,  an  artificial  anus  should  at  once  be  formed  in  the 
left  lumbar  region,  as  being  a  safer  proceeding  than  the 
attempt  to  open  the  rectum  from  the  perineeal  region. 

Tiingel,  one  of  the  latest,  and  a  most  able  writer  on  this 
subject,  says  that — "  The  operation  for  abdominal  artificial 
anus  should  be  employed  for  all  forms  of  imperforate  anus  ; 
it  being  manifestly  the  most  rational,  and  with  a  certain  limit 
may  always  be  employed  ;  for  we  cannot  decide  beforehand 
whether  we  shall  succeed  in  finding  the  rectum,  or  in  draw- 
ing it  down  to  the  skin  of  the  perinseum,  when  it  is  found." 
( Uher  Kunstliche  Afterbildung.  S.  203.    Keil :  1853.) 

The  fact  of  our  being  sometimes  unable  to  decide  at  first, 
as  to  whether  we  shall  succeed  or  not  in  finding  the  end  of 
the  rectum,  is  a  very  weak  argument  against  the  formation 
of  a  perineal  artificial  anus,  and  no  argument  whatever  in 
favor  of  an  abdominal  artificial  one.  Our  not  knowing 
exactly  whether  we  shall  find  the  rectum,  is  no  reason  why 
we  should  not  search  for  it,  and  endeavor  to  find  it,  and  when 
found,  try  to  bring  down  the  end  of  it,  and  form  an  anus  in  its 


ABDOMINAL   ARTIFICIAL   ANUS.  297 

normal   situation;    failiiifj   in    this,    it    is    still    tiiiu;    ciioiioji 
to  establish  the  amis  in  the  abdomen.  Again,  Tiingel  ixiiiarks 
that — "  We  must  not  forget  that  although  the  artificial  anus 
in  the  perinseum  has  its  seat  near  the  natural  one,  it  never- 
theless causes  inconveniences  equally  as  great  as  the  artiticial 
anus  made  elsewhere  ;  the  liquid  fseces  are  constantly  escap- 
ing, whilst  those   which   are  solid  are  voided  with  difficulty. 
The  cases  in   which   defecation  occurs  voluntarily,   notwith- 
standing the  absence  of  the  sphincter  and  the  levator  ani,  can 
only  be  explained  by  the  fact,  that   the  contraction  of  the 
artificial  anus  opposes  an  obstacle  to  the  passage  of  the  faeces, 
to  be  overcome  only  by  the  pressure  of  the  abdominal  mus- 
cles ;  thus  the  influence   of  the  will  is  possible  in  the  act  of 
defecation.     But  as  a  compensation  for  this  phenomena  of 
voluntary   evacuation,    the    patient   endures   a   still   greater 
suflering  resulting  from  difficult  and  incomplete  evacuation, 
which  may  result  fatally ;  whilst  the  artificial  anus  in  the 
abdomen,  enables  us  to  prevent  or  combat  the  contraction, 
and  by  j)roper  bandages  to  hinder  the  constant  and  involun- 
tary  evacuation   of  fsecal   matter ;   and  even   when   this   is 
impossible,  this   unfortunate  condition  of  the  patient  by  no 
means  endangers  life.     The  presence  of  the  sphincter  in  some 
cases  of  imperforate  anus  seems  incontestible,  but  it  is  rare, 
and  still  more  rare  are  cases  in  which  it  has  been  possible  to 
preserve   the   sphincter  in   the  operation,    as   was  done  by 
MM.  Roux  and  Goyraud.     Apart  from  tliese  rare  instances, 
the  artificial  anus  in  the  perinseum  ought  not  to  be  regarded 
as  much  more   advantageous   than   one   in   the  abdomen." 
{Loco  citato.) 

The  opinion  of  Tiingel  that  the  perinaeal  artificial  anus  has 
no  preference  over  the  abdominal  one,  except  merely  that 
of  being  located  in  its  natural  situation,  is  the  very  best 
reason  that  could  be  given  why  it  should  not  always  be  pre- 
ferred to  the  abdominal  artificial  anus ;  for  as  it  regards  con- 
stipation, it  is  by  no  means  a  matter  of  indifi'erence  whether 


298  ABDOMINAL   ARTIFICIAL   ANUS. 

the  contents  of  the  intestines  pass  by  the  rectum  and  perineal 
anus,  or  reach  only  the  opening  at  the  sigmoid  flexure  of  the 
colon.  The  suppositions  of  Tiingel  with  regard  to  the  perin- 
seal  artificial  anus  causing  as  much  inconvenience  as  one  in 
any  other  situation,  and  the  other  various  difficulties  and 
troubles  which  he  enumerates,  are  certainly  not  in  accordance 
with  facts,  as  any  one  can  convince  himself  by  carefully 
examining  the  numerous  cases  successfully  treated,  and  which 
will  be  found  reported  in  this  work.  He  has  certainly 
forgotten  to  recall  to  mind  the  many  dangers  and  difficulties 
which  accompany  the  formation  of  an  anus  in  the  abdomen. 
In  the  abdomen  no  dilator  and  constrictor  muscles  ever  exist, 
and  the  faecal  matter  cannot  be  retained  except  by  a  compress 
and  bandage  ;  unless  by  the  lucky  prolapsus  of  a  fold  of  the 
intestine  taking  place  across  the  aperture,  filling  it  up  and 
acting  as  a  valve,  and  thus  preventing  the  efflux  of  the  faeces, 
as  occurred  at  the  artificial  opening  in  the  stomach  of  the 
celebrated  Alexis  Saint-Martin. 

These  authors  have  entirely  failed  to  prove  that  the  abdo- 
minal artificial  anus  has  any  preference  whatever  over  the 
perinaeal  artificial  one,  or  that  it  is  in  any  respect  a  good 
substitute  for  it. 

Some  very  able  surgeons  denounce  the  operation,  and  con- 
tend that  no  practitioner  is  ever  justifiable  in  performing  it. 
This  is  the  other  extreme. 

Professor  Bigelow,  of  Boston,  whom  we  have  already 
noticed,  thinks  it  unnecessary  to  discuss  the  question  of 
"  ekeing  out  the  life  of  a  new-horn  haby  ly  an  artificial  anus 
in  the  groin  or  hackP  {Boston  Medical  and  Surgical  Jour- 
nal.   Vol.  L  YII.  p.  512.     Boston :  1858.) 

I  would  observe  that  Dr.  Bigelow  is  by  no  means  alone  in 
his  views  of  the  impropriety  of  performing  colotomy  in  the 
case  of  new-born  children.  The  very  distinguished  Professor 
of  Surgery,  Dr.  Gross,  of  the  Jeff'erson  Medical  College  of 
Piiiladelphia,  says  in  relation  to  this  gperation  {colotomy) — 


ABDOMINAL    ARTIFICIAL    ANUS.  299 

"  We  are  struck  with  astonishment  that  any  one  possessed  of 
tlio  proper  feelings  of  humanity,  eliould  seriously  advocate  a 
procedure  so  fraught  with  danger  and  followed,  if  successful, 
by  such  disgusting  consequences.  I  cannot,  I  must  confess, 
appreciate  the  benevolence  which  prompts  a  surgeon  to  form 
an  artificial  outlet,  for  the  discharge  of  the  faices,  in  a  case  of 
imperforate  anus,  in  a  child  in  whom  the  rectum  is  either 
completely  absent,  or  terminates  blindly  several  inches  above 
its  normal  situation  ;  or  in  a  case  of  scirrhus  of  the  bowel  in 
an  adult,  in  whom,  from  the  very  nature  of  the  disease,  life 
cannot  possibly  be  prolonged  beyond  a  few  brief  weeks  or 
months  at  farthest.  Let  the  surgeon,  if  he  be  a  parent,  ask 
himself  the  question,  whether  he  would  not  rather  see  his 
child  die  without  an  attempt  at  relief,  than  to  place  it  in  a  con- 
dition that  would  only  render  it  an  object  of  disgust  to  itself, 
and  of  loathing  to  every  one  around  ;  or  if  he  be  a  husband, 
whether  it  would  not  be  more  in  consonance  wdth  the  dictates 
of  humanity  to  abandon  his  wife  to  her  fate,  than  to  imder- 
take  to  eke  out  for  her  a  miserable  existence  by  sncli  a  pitiful 
and  revolting  an  expedient  ?  I  have  performed  the  operation 
but  once,  and  I  am  sure  nothing  could  ever  induce  me 
to  attempt  it  again.  While  it  is  impossible,  I  conceive, 
to  bestow  too  much  praise  npon  those  who  first  conceived 
and  executed  the  design  of  affording  aid  to  this  unfortunate 
class  of  sufferers ;  it  is  evident  from  the  statistics  which  have 
been  published  upon  the  subject,  and  to  which  special  refer- 
ence will  be  made  by  and  by,  that  the  operation  is  founded 
npon  a  misdirected  sympathy,  and  that  it  ought  to  be 
discarded  as  among  obsolete  devices  of  surgery."  (A  System 
of  Surgery.  Vol.  II.  Chap.  XIII.  p.  765.  Philadelphia  : 
1859.) 

M.  Fourcart,  in  alluding  to  the  lumbar  artificial  anus 
according  to  the  method  of  Callisen,  says — "  I  will  repeat, 
that  in  ray  opinion,  the  surgeon  has  no  right  to  impose 
this   operation  upon  a  child,   and  should  not  do  so,  unless 


300  ABDOMINAL   ARTIFICIAL   ANUS. 

forced   by  the   formal   demand   of    the    parents."   {Gazette 
des  Hopitaxix  de  Paris.   N'o.  LXX.    Juin  16,  1835.  jp.  280.) 

I  should  think  that  no  prudent,  or  intelligent  surgeon,  even 
if  he  had  the  right,  would,  under  any  circumstance,  impose 
upon  the  ciiild  any  operation,  especially  one  in  which  he  had 
no  confidence  ;  and  no  sensible  parents  would  ever  make 
such  a  demand  ;  if  they  did,  I  trust,  for  the  honor  of  the  pro- 
fession, that  no  surgeon  would  be  found  to  comply  with 
it.  The  duty  of  the  surgeon  is  one  thing,  that  of  the  parents 
altogether  another. 

On  one  occasion  the  able  and  distinguished  M.  Paul 
Dubois,  at  present  accoucheur  to  the  Empress  Eugenie,  w^as 
called  in  consultation  with  M.  Fourcart  to  see  a  child  having 
an  imperforate  anus.  In  consequence  of  the  difficulties 
attendins:  this  case,  the  formation  of  an  abdominal  artificial 
anus  after  the  method  of  Callisen,  was  spoken  of;  when  M. 
Dubois  remarked,  that  if  it  were  the  case  of  his  own  child, 
he  would  not  consent  to  the  performance  of  such  an  opera- 
tion. The  parents  of  the  child,  however,  insisted  upon  it,  and 
these  two  surgeons  were  forced  to  yield,  and  to  seek  for  the 
colon  in  the  lumbar  region.  The  child,  however,  died  in  a 
few  days  afterwards. 

I  will  repeat,  that  when  the  surgeon  has  entirely  aban- 
doned all  hope  of  making  a  perinseal  artificial  anus,  it  is  his 
duty  to  propose  to  the  parents  or  friends  of  the  child, 
to  establish  an  artificial  anus  in  the  abdomen ;  explaining  to 
them,  that  an  anus  in  so  unnatural  and  inconvenient  a  situa 
tion  as  the  iliac  or  lumbar  region,  is  indeed  a  very  sad  alter- 
native, nevertheless,  as  it  offers  the  only  chance  of  preserving 
the  life  of  the  child  which  otherwise  must  inevitably  perish, 
it  should  be  established.  Should  the  parents,  however, 
in  behalf  of  their  child,  come  to  the  conclusion,  that  death 
would  be  preferable  to  life,  encumbered  with  such  an  infirm- 
ity, it  would  then  be  entirely  left  for  tl:\em  to  refuse  their  con- 
sent to  the  operation. 


ABDOMINAL    AKTIFICIAL   ANUS.  301 

Some  surgeons  seem  to  think  that  tlie  proposition  to 
perform  this  operation,  should  always  first  ct»me  from  the 
parents  of  the  child,  whereas  nothing  should  come  from  them 
but  their  consent  to,  or  their  rejection  of  it.  T  would  like  to 
understand,  what  the  parents  would  be  likely  to  know,  con- 
cerning the  necessity  or  propriety  of  such  an  operation,  that 
the  proposition  to  perform  it,  should  come  from  them.  If  the 
operation  confers  any  good  w^hatever,  the  proi)osition  to  per- 
form it  should  come  from  the  surgeon.  If  it  confers  nothiuir 
but  death,  or  a  miserable  life,  no  surgeon  should  perform  it 
even  if  urged  to  do  so  by  the  parents.  Any  other  course 
would  be  undignified  and  absurd. 

In  my  opinion,  in  by  far  the  largest  number  of  cases  of 
congenital  imperforation  of  the  rectum  and  sams,  proctoplasti/, 
in  its  j)resent  improved  state,  as  presented  in  this  work,  will 
doubtless  succeed  ;  and  in  those  rare  instances  in  which  it  is 
entirely  impracticable,  the  surgeon  should  not  hesitate  for  a 
moment  to  perform  the  iliac  or  the  lumbar  operation.  It  is 
true,  we  observe  how  eloqnently  and  how  earnestly  the  oppo- 
site is  maintained,  namely,  that  no  surgeon  is  justified,  under 
any  circumstance,  in  prolonging  the  life  of  a  child  in  whom 
the  rectum  and  anus  are  imperforate,  upon  as  it  is  said,  the 
loathsome  condition  of  an  abdominal  artificial  anus,  I,  on 
the  contrary,  however,  maintain  that  such  an  opinion  cannot 
be  justified  upon  any  principle  of  morality,  since  an  impera- 
tive obligation  and  duty  rest  upon  the  surgeon,  to  employ  to 
the  best  of  his  ability,  the  means  placed  at  his  command  for 
the  relief  of  human  suffering  and  the  prolongation  of  human 
life.  The  principles  of  our  art,  as  w^ell  as  the  dictates  of 
humanity  itself,  command  us  to  avail  ourselves  of  this  opera- 
tion, notwithstanding  it  has  been  stigmatized  as  a  ^^pitiful 
and  revolting  exj^edient.''^ 

M.  Araussat,  when  speaking  on  this  very  subject,  says — 
"  An  artificial  anus  in  the  lumbar  region  is  no  doubt  a  great 
infirmity,  but  it  is  the  sine  qiia  non — life  or  death.     1  have 


302  ABDOMINAL  ARTIFICIAL   ANUS. 

heard  some  persons  say,  '  I  should  prefer  death  to  life  with 
such  an  infirmity.'  I  have  assured  them  that  they  were  not 
in  a  position  to  decide  ;  and  I  have  no  confidence  in  these 
courageous  resolutions  taken  when  one  is  sound  in  health  ; 
for  in  the  cases  of  the  afflicted,  to  whom  this  operation  has 
been  proposed,  if  some  have  refused  at  first,  all  have  ended 
by  demanding  it  most  earnestly.  Talma  and  Broussais  would 
doubtless  have  accepted  it  as  a  blessing. 

"  I  have  already  said,  and  I  repeat  it,  this  infirmity  is  not 
80  great  as  is  generally  believed,  because  it  is  always  com- 
pared to  that  wbich  results  from  stercoracious  fistulse  of  the 
small  intestine.  But  it  is  important  to  observe,  that  the  arti- 
ficial anus  of  the  large  intestine  is  not  to  be  compared  with 
the  accidental  anus  of  the  small  intestine,  which  always 
occurs  in  gangrened  hernia.  In  this  case  there  is  always 
incontinence  of  faecal  matter,  which  is  almost  always  liquid. 
In  the  artificial  lumbar  anus  of  the  colon,  there  is  often,  con- 
stipation, on  the  contrary,  and  almost  always  a  difficulty  in 
defecation,  rather  than  too  much  facility  ;  consequently  with 
cleanliness,  and  a  tent  well  applied,  this  infirmity  is  much 
more  endurable  than  is  commonly  thought,  since  the  faeces  do 
not  flow  involuntarily  and  constantly,  and  there  is  no  need  of 
a  box  or  pouch  as  in  case  of  the  accidental  anus. 

"  Notwithstanding  all  the  slui-s  which  are  so  easily  cast  upon 
this  sort  of  infirmity,  it  may  be  said  to  be  more  endurable  than 
many  others,  because  it  is  naturally  concealed  and  easily  kept 
secret ;  it  is  far  better  therefore,  in  view  of  what  I  have  said, 
to  have  an  artificial  anus,  than  to  have  a  deformity  which  for- 
ces itself  upon  the  eye,  and  oflTends  everybody."  {L'Exam- 
inateur  Medical  de  Paris.  Annee  18i3.  tome  III.  p.  234:.) 

I  am  not  aware,  that  any  surgeon  in  the  United  States,  has 
ever  performed  the  operation  for  abdominal  artificial  anus  on 
an  imperforate  infant.  If  there  is  such  a  case  reported,  I 
have  not  seen  the  record. 

I  will  here  remark,  although  it  may  appear  out  of  place, 


ABDOMINAL   ARTIFICIAL   ANUS.  303 

that  should  the  surgeon  ftiil  to  form  an  artificial  anus  in  the 
periiuie.um,  tlic  abdominal  operation  should  l)e  postponed, 
provided  the  condition  of  the  child  admitted  of  delay, 
until  it  recovered  from  the  exhaustion,  consequent  upon  pain 
and  loss  of  blood,  so  as  to  enable  it  the  better  to  endure  the 
second  operation.  By  this  delay  too,  the  rectum  perchance 
might  in  the  meantime  present  itself  in  the  incision  in  the 
perinaeum,  sufficiently  low  down  to  be  recognized ;  for  its 
superior  portion  would  be  gradually  becoming  more  and  more 
distended  with  meconium,  and  constantly  impelled  down- 
wards by  the  natural  efforts  of  the  child  to  evacuate  its  bow- 
els. A  case  of  this  character  is  related  by  M.  Petit  [Vide 
Case  LIII.]  in  which  a  surgeon  failed  to  find  the  rectum 
through  the  incision  which  he  had  made  in  the  perineal 
region  ;  but  another  surgeon  three  hours  after,  found  the  blind 
end  of  the  rectum  distended  with  meconium,  and  protruding 
through  the  wound.  {Memoire  de  VAcadeinie  Royale  de 
Chirurgie  de  Paris.  Annee  1781.  tome  II.  p.  237.) 

It  is  of  the  greatest  importance  to  the  success  of  the  opera- 
tion for  the  creation  of  an  abdominal  artificial  anus,  that 
great  care  should  be  taken  to  protect  the  cavity  of  the  abdo- 
men against  the  intrusion  of  liquids  ;  that  the  finger  should 
be  introduced  in  the  most  gentle  manner  into  the  abdominal 
wound  in  search  of  the  intestine  ;  as  it  makes  a  very  essential 
difl:erence,  whether  the  intestine  to  be  opened,  protrudes  at 
once  in  the  wound  of  the  abdomen,  or  whether  the  finger  has 
to  be  employed  to  search  for  it.  It  is  also  of  the  highest 
importance  that  the  little  patient  should  be  kept  warm,  and 
well  nursed  to  sustain  it.  Immediately  after  the  operation  it 
should  be  put  into  a  warm  emollient  bath,  and  then  placed  in 
the  arms  of  its  mother  in  bed,  so  that  the  warmth  of  the 
mother  and  the  bed  should  be  communicated  to  it.  For  the 
want  of  these  precautions  cases  are  often  lost. 


SOi  ABDOMINAL   AKTIFICIAL   ANUS. 

SECTION    II. 
HISTORY  OF   THE  OPERATION, 

It  is  a  singular  circumstance  in  the  history  of  the  formation 
of  ahdoininal  artificial  amis,  that  two  surgeons,  Littre  and 
Callisen,  who  never  performed  the  operation  on  a  living  sub- 
ject, and  who  never,  as  far  as  is  now  known,  published  any  ex- 
act method  of  performing  it,  should  be  so  universally  acknow- 
ledged as  the  authors  of  the  two  distinguished  and  highly  im- 
portant methods  of  operating  now  adopted. 

I  will  confine  myself  to  the  history  of  the  operation  so  far 
only  as  it  relates  to  cases  of  congenital  malformation.  It  com- 
mences with  M.  Littre,  an  eminent  French  anatomist,  and 
Member  of  the  Royal  Academy  of  Sciences.  He  was  the 
first  individual  in  modern  times,  who,  in  certain  cases  of  con- 
genital malformation  of  the  rectum,  suggested  the  idea  of 
establishing  an  artificial  anus  in  the  abdomen,  when  in  sucli 
cases,  it  was  found  altogether  impossible  to  re-establish  the 
natural  one  in  the  perinseum.  This  idea  appears  to  have  been 
the  result  of  reflections  suggested  from  having  examined  post- 
mortem an  infant  which  had  died  of  an  imperforation  of  the 
rectum,  six  days  after  birth.  At  the  autopsy  in  this  instance 
M,  Littre  found  the  rectum  normal,  both  below  and  above  a 
complete  obstruction  which  divided  this  intestine  into  two 
parts,  presenting,  as  it  were,  a  double  cul-de-sac,  directly  op- 
posite each  other.  [  Vide  Case  C] 

The  main  idea  of  M.  Littre  seems  to  have  been,  to  recom- 
mend in  all  future  cases  of  this  character,  a  double  operation — 
that  is  the  opening  of  the  abdomen  at  some  point,  and  through 
such  w^ound,  the  excising  of  the  obstructed  portion  of  the  rec- 
tum, and  the  uniting  again  by  suture  of  its  divided  portions,  and 
if  successful  in  this,  the  wound  of  the  abdomen  to  be  healed  ; 
failing,  however,  in  this  proceeding,  then  to  unite  the  superior 
portion  of  the  rectum  to  the  wound  in  the  abdomen,  and  thus 
create  an  abdominal  artificial  anus.  This  is  dimly  shadowed 
forth  in  his  description  of  the  case  alluded  to,  and  in  the  fol- 


ABDOMINAL    AUTIFICIAL    ANUS.  305 

lowing  liiiignagc  which  appears  to  ])e  all  iliaf  is  said  mi  t]\v 
Biihject.  "  11  faiidrait  faire  un  incision  auventre,  etreeowJre 
ensevMe  les  deux  parties  a2?rcs  les  avoir  7'ouveries,on  dn  m.'dns 
faire  mnir  la  partie  superieure  de  V intestine^  a  la  plaie  da 
ventre^  (pie  Von  ne  refermemer  ait  jamais,  et  quiferait  la  f una- 
turn,  d'anus^''  {Hlstoire  de  VAcademie  Royali  des  Sciences  de 
Paris.     Annee  1710.    jr>.  30.) 

There  is  nothing  revealed  here,  however,  \\\t\\  regard  to  the 
exact  locality  of  the  abdominal  aims,  or  with  regard  to  the 
manner  of  performing  the  operation.  Not  a  word  is  said 
about  cutting  into  the  cavity  of  the  peritonaeum  in  the  left  iliac 
region,  opening  the  sigmoid  flexture  of  the  colon,  securing  the 
opened  intestine  in  contact  with  the  abdominal  wound  by 
means  of  a  thread  passed  through  the  mesentery,  &c.  Tlie 
idea,  however,  of  an  abdominal  artificial  anus  is  here  clearly 
enough  suggested  by  M.  Littre. 

It  is  singular  that  not  an  author,  for  more  than  half  a  cen- 
tury, who  wrote  on  the  subject  of  imperforate  anus,  commenc- 
ing from  M.  Littre  himself,  ever  mentioned  the  important  pro- 
position which  this  illustrious  anatomist  had  proposed  in  1710. 

M.  Pillore,  a  distinguished  surgeon  of  Rouen,  was  really 
the  first  individual  who  acted  \\^on  the  suggestion  of  Littre, 
or  upon  his  own  suggestion,  from  having  witnessed  several 
cases  of  preternatural  or  accidental  anus  which  had,  within  a 
short  period  previously,  come  under  his  own  observation. 
Pillore  in  1776,  just  sixty-six  years  after  the  proposition  of  M. 
Litti-e  had  been  published  by  M.  Fontenelle,  the  Permanent 
Secretary  of  the  Academy  of  Sciences,  executed  in  a  modified 
form  the  operation  of  Littre,  under  circumstances,  it  is  true, 
not  contemplated  by  Littre.  The  patient  of  Pillore  was  an 
adult,  a  wine  merchant  in  the  vicinity  of  Kouen,  and  the 
operation  was  performed,  not  in  consequence  of  a  congenital 
malformation  of  the  rectum,  but  on  account  of  a  complete  ob- 
struction to  defecation,  caused  by  a  scirrhus  contraction  of  the 

superior  part  of  the  rectum,  and  the  inferior  portion  of  the 
2U 


306  ABDOMINAL   ARTIFICIAL   ANUS, 

colon.  In  this  instance  Pillore  formed  the  artificial  anus  in 
the  caecum  which  was  opened  through  the  peritonaeum.  The 
patient  survived  the  operation  twenty-eight  days,  and  the  im- 
mediate cause  of  his  death  seems  to  have  been  intense  inflam- 
mation of  the  jejunum,  caused  by  two  pounds  of  metallic  mer- 
cury having  been  administered  a  month  previous  to  the  oper- 
ation, and  which  had  lodged  in,  and  displaced  tnat  portion  of 
the  small  intestine.  {Actes  de  laSociete  de  Lyon.  Annee  1797. 
ip.  189.  Also,  Amussat.  Menioire  sur  la  PossihilitS  d'etahllr 
un  Ames  artijiGiel  dans  le  Region  loriibairS  sans  penetrer 
dans  le  Peritoine.     Paris  :  1839.) 

To  M.  Pillore  then,  is  justly  due  the  merit  of  having  formed 
the  first  abdominal  artificial  anus  in  a  living  subject,  and  with 
him  commenced  that  series  of  operations  for  this  purpose 
Mdiich  I  will  presently  give,  confining  myself,  however,  en- 
tirely to  those  cases  in  which  the  operation  was  performed  on 
account  of  congenital  malformation  of  the  rectum. 

M.  Dubois  was  the  first  surgeon  who  ever  dared  to  execute 
the  operation  of  Littre  on  a  living  imperforate  infant.  This 
he  did  in  1783,  just  seventy-three  years  after  the  promulgation- 
of  Littre's  proposition,  and  seven  years  after  Pillore's  opera- 
tion.    [  Vide  Case  CCL  F.] 

We  must  now  introduce  the  celebrated  Callisen,  a  highly 
distinguished  surgeon  of  Copenhagen,  who  as  early  at  least  as 
1770,  published  another  method  of  forming  an  abdominal  arti- 
ficial anus,  intended  doubtless  as  a  great  improvement  on 
Littre's  method,  rendering  that  operation,  as  Avas  supposed, 
less  dangerous.  Tlie  operation,  which  is  universally  attri- 
buted to  him,  consists  in  opening  the  descending  colon 
from  the  lumbar  region  without  wounding  the  peritonaeum. 
It  is  not  known  with  whom  this  operation  originated; 
Calissen  liimself  does  not  claim  the  distinguished  honor  of 
first  suggesting  it.  M.  Sabatier  was  tlie  first  surgeon  who 
attributed  this  proposition  to  Callisen.  All  Callisen  himself 
says    in    relation   to    it,    is  briefly   as    follows  : — "  Si  cavum 


ABDOMINAL    ARTIFICIAL    ANUS.  307 

intcsthiale  cultro  vcl paraccnteslo  attinr/l  ncqueai^  vix  servari 
potei'it  ceger.  Qua) proposita  suh  Jioc  reruiri  static  fuit  incisio 
intesiini  cceci  vel  coli  descendentis^  sectione  in  regione  lumhari 
unistra  ad  marglnetn  musculi  quadrati  lamhorum  facta^  ut 
anus pai'etur  artificiaUs,  remedium  pnnhet  oinnio  incerimro 
iitqne  hac  operatione  vix  vita  miscUi  servari  poterit.  Quan- 
gaavi  intestinuni  in  hoc  loco  facilms  aitingatur^  qxiam  s\ip<'a 
reglonein  inguinalemy  {Sijstema  Chlrurgie  Ilodiernce.  tome 
IT.  p.  842.     IlafmoB:  1817.) 

We  observe,  by  this  language  that  Calliseii  intimates  that 
the  operation  was  proposed  by  some  one  else,  but  by  whom 
he  does  not  say.  lie  neither  claims  it  as  original  with  him- 
self, nor  does  lie  at  all  allude  to  the  great  distinguishing  fea- 
ture of  it — the  preservation  of  the  peritonaeum.  The  truth  is 
that  very  little  is  known  in  relation  to  the  early  history  of 
this  operation,  and  that  little  by  no  means  favorable  to  it. 

The  peculiar  advantages  claimed  for  Callisen's  proceeding 
over  that  of  Littre,  are — first,  the  integrity  of  the  perito- 
naeum— ■second,  the  more  convenient  situation  of  the  artificial 
anus,  and  third,  the  less  liability  in  this  situation  to  prolapsus 
of  the  intestine. 

M.  Sabatier  mentions  that  Callisen  himself  experienced 
great  difficulty  in  executing  this  operation  on  the  dead  body, 
having  failed  in  numerous  instances,  in  consequence  of  una- 
voidably opening  the  peritonaeum.  He  gives  an  instance  in 
which  Callisen  attempted  this  operation  on  the  body  ot  a 
child  which  had  died  of  a  malformation  of  the  rectum,  and 
failed,  by  having  opened  the  peritonaeum  ;  but  in  his  second 
effort  on  the  same  subject,  he  barely  succeeded,  by  making 
his  second  incision  further  back,  and  by  introducing  his  fin- 
gers into  the  first  incision,  in  order  to  fix  the  intestine. 
{Medicine  Operatoire,  tome  III.  p.  337.  ^d  Edit.  Paris  : 
1824.) 

Callisen's  operation  was  indeed,  with  but  few  exceptions, 
almost  universally  condemned.     Among  the  numerous  sur- 


308  ABDOMINAL   ARTIFICIAL    ANUS. 

geons  who  of  late  years  condemned  it,  and  wlio  aided 
ill  keeping  it  consigned  to  oblivion,  I  will  mention  M.  le 
BaroQ  Dupnytren  ;  {Dlctionnaire  de  Medicine  et  de  Chirtir- 
gie  Pratiques,  tome  III.  p.  12S)  and  Mr.  Fergnsson,  wlio,  in 
relation  to  this  operation,  says — "  I  am  inclined  to  think  that 
a  proposal  to  cut  into  any  portion  of  the  left  side  of  the  colon 
without  injuring  the  peritonaeum,  either  in  the  young  or  the 
old  subject,  must  have  been  made  from  a  very  limited 
anatomical  experience ;  for  from  what  I  have  seen,  I  am 
positive  that  not  one  case  in  twenty  would  have  admitted  of 
an  operation  of  the  nature  proposed.  I  make  this  statement 
as  to  numbers,  however,  merely  at  random,  not  having  kept 
any  exact  account."  {Edinhurgh  Medical  and  Surgical  Jour- 
nal. 1831.  j^.  366.)  There  never  were  at  any  time  but  a  few 
surgeons  who  were  in  favor  of  Callisen's  method.  M.  Allen, 
who  alone  as  it  were  in  1780,  was  of  the  opinion  that  it  was 
well  worthy  of  further  consideration.  {Recueil  Periodique  de 
la  Societe  de  Medicine  de  Paris,  tome  I.  p.  123.) 

This  was  the  estimation  in  which  Callisen's  operation  was 
held,  when  M.  Amussat,  in  1839,  took  the  first  step  towards  re- 
viving and  improving  it ;  whether  for  the  real  benefit  and 
advancement  of  surgery,  is  a  question  not  yet  decided.  This 
step  was  taken  on  the  first  day  of  October,  1839,  by  reading 
and  defending,  before  the  Royal  Academy  of  Medicine, 
a  paper  which  I  have  already  noticed  in  this  work,  entitled  : 
"  Memoire  sur  la  PossibilitS  d''  etablir  un  Anus  artifidel 
dans  la  Pegion  lonibaire  sans  penetrer  dans  le  Peritoine^ 
This  paper  was  soon  followed  up  by  two  others  on  the  same 
subject ;  one  on  the  sixth  of  September,  1841,  and  the  other 
on  the  fourth  of  July,  1842, 

This  able  and  distino-uished  suro:eon  in  the  series  of  mas- 
terly  papers  on  this  subject,  read  before  the  Royal  Academy 
of  Sciences,  investigates  most  critically,  in  highly  chaste  and 
beautiful  language,  the  diff'erent  methods  heretofore  existing 
of  forming  an  artificial  anus  ;  gives  their  history  ;  points  out 


ABDOMINAL   ARTIFICIAL    ANUS.  309 

their  numerous  defects;  endeavors  to  establisli  flx('(l  rnlo^  of 
practice,  founded  upon  accurate  anatomical  investif^ations, 
instead  of  the  vague  and  uncertain  ones  existing,  and  endea- 
vors to  substitute  impi-ovcd  methods  of  operating,  &c. 

M.  Amussat  was  therefore  the  first  surgeon  wlio  had  tlie 
courage  and  the  ingenuity  to  revive,  to  modify  and  to  execute 
Callisen's  operation,  of  opening  tlie  left  lumbar  colon  Avithout 
wounding  the  peritonfeum.  If  he  has  no  claims  to  originality 
of  conception  in  doing  this,  he  certainly  can  claim  the  whole 
merit  of  reviving,  improving  and  re-introducing  an  operation 
which  was  universally  condemned  and  consigned  to  oblivion, 
in  consequence  of  the  unavoidable  and  insurmountable  diffi- 
culties and  dangers  which  were  believed  necessarily  to  attend 
it  in  all  cases. 


SECTION     III. 

THE     PROCEEDING     OF    LITTRI^, 

The  different  steps  of  the  method  of  forming  an  abdominal 
artificial  anus  in  the  left  iliac  region,  attributed  by  universal 
consent  to  M.  Littre,  are  as  follows  : 

The  little  patient  should  be  placed  on  its  back  on  a  pillow, 
Math  its  thighs  extended,  and  supported  in  this  position 
by  one  or  two  assistants.  The  surgeon  being  conveniently 
situated,  should  make  an  incision  in  the  left  iliac  region  of 
from  one  and  a  half  to  two  inches  in  length,  between  the 
antero-superior  spinous  process  of  the  ilium  and  the  pubis,  a 
little  above  and  almost  parallel  to  Poupart's  ligament.  He 
should  then  successively  divide  the  skin,  fascia  superficialis, 
aponeurosis  of  the  obliquus  externus,  the  lower  fibres  of 
the  obliquus  internus,  and  the  fascia  transversalis ;  pro- 
ceeding, however,  more  cautiously  as  he  approaches  the  peri- 
tonaeum, which  after  being  reached  and  well  exposed,  should 
be  pinched  up  and  perforated,  and  then  divided  w'ith  a  bis- 


S10  ABDOMINAL    ARTIFICIAL   ANUS. 

touiy,  on  a  grooved  director,  to  tlie  same  extent  as  the 
incision  in  the  integument.  Tlie  sigmoid  flexure  of  the  colon, 
distended  with  meconium,  usually  siDontaneouslj  presents  it- 
self at  the  back  part  of  the  opening,  and  may  generally  be 
recognized  by  its  livid  or  its  greenish  color,  by  the  aspect  of 
its  external  envelope,  and  arrangement  of  its  fibres.  It  may 
also  be  distinguished  by  the  resistance  of  the  mesentery 
which  comes  from  the  right  side,  whilst  the  resistance  of  the 
iliac  meso-colon  is  felt  from  the  left.  It  sometimes,  but  rarely 
ever  happens  that  immediately  after  the  peritongenm  is 
opened,  that  a  portion  of  small  intestine  protrudes  ;  and  from 
its  great  distention  and  its  dark  color,  caused  by  inflamma- 
tion, might  lead  to  some  doubt ;  a  very  slight  examination, 
however,  will  enable  the  operator  to  distinguish  it  from  the 
sigmoid  flexure  of  the  colon.  The  surgeon  should  now  intro- 
duce into  the  incision  the  index  finger  of  his  left  hand  and 
seize  the  intestine  and  bring  it  outwards  as  far  as  possible, 
the  finger  acting  as  a  hook  for  this  purpose  ;  whilst  with  the 
right  hand  a  larcje  soft  ligature  should  be  carried  throuorh  its 
mesentery  by  means  of  a  curved  silver  needle,  in  order  to  re- 
tain it  in  this  position.  A  longitudinal  incision  should  now 
be  made  into  the  intestine,  and  its  contents  evacuated.  BotJi 
ends  of  the  bowel  should  be  well  washed  out  by  injecting 
warm  flax-seed  tea,  or  warm  milk  and  water,  and  the  thread 
in  the  mesentery  should  be  fastened  to  the  parietes  of  the 
abdomen  ;  after  which  a  tent  of  lint  besmeared  with  simple 
cerate  should  be  carefully  introduced  to  prevent  adhesion  of 
the  lips  of  the  wound,  and  a  fold  of  linen  dipped  in  cold 
water,  or  a  warm  poultice  applied  to  the  lower  part  of  the 
abdomen.  Care  should  be  taken  for  some  time  after,  that 
the  new  anus  should  not  contract  too  much. 

It  has  been  proposed  to  unite  the  edges  of  the  intestinal 
wound  to  those  of  the  external  by  four  or  more  points  of 
intercepted  suture,  and  the  extremities  of  the  external  v/ound 
closed  by  the  twisted  suture.     This  would  be  decidedly  pre- 


ABDOmNAL    AKTIMCIAL    ANUS.  311 

fci'iible  to  the  other  methud,  uiid  iiuike  ii  much  more  comj)leto 
jind  handsome  operation.  [  Vide  Plate  XV.  Fiys.  3,  4.J 

Should  any  htemorrluige  occur  durhig  tlie  early  stai^e  of 
tlie  operation,  the  bleediii;^  vessels  should  be  immediately 
tied,  to  prevent  the  subsequent  stages  from  being  obscured. 


SECTION    I  Y  . 

CASES     AND     REMARKS. 

The  following  are  all  the  cases,  so  far  as  my  knowledge  ex- 
tends, in  which  the  operation  of  M.  Littre  was  executed  for 
congenital  malformation  of  the  rectum  and  anus,  and  are  all 
the  data  upon  which  surgeons  are  at  present  proceeding  in 
such  cases : 

Case  CCLV, — Professor  A.  Dubois  was  the  first  surgeon 
who  in  a  case  of  cono-enital  malformation  of  the  rectum  and 
anus,  put  into  execution  the  operation  which  M.  Littre  Iiad 
proposed  so  many  years  previously,  namely,  the  establish- 
ment of  an  iliac  artificial  anus.  In  this  instance  the  child 
was  three  days  old,  presenting  an  imperforation  of  tlie  anus 
and  rectum,  no  trace  whatever  of  an  anus  being  visible.  M. 
Dubois  performed  the  operation  in  December,  17S3,  but 
unfortunately  the  child  died  ten  days  afterwards. 

At  the  autopsy  it  was  observed  tliat  the  edges  of  the  intes- 
tinal wound  were  consolidated  with  those  of  the  abdominal 
wound.  Tills  appears  to  be  all  that  is  known  in  relation  to 
this  case.  {Recueil  Periodique  de  la  Societe  de  Medicine  de, 
Paris,  tome  HI.  p.  125.  Also,  Dictionnawe  de  Medicine  et 
de  Chirurgie  Pratiques,  tome  III.  ]).  128.) 

Case  CCLVI. — A  male  infant  thirty-eight  hours  old  was 
brought  to  M.  Duret,  a  distinguished  naval  surgeon  at  Brest. 
In  this  case  there  was  not  the  sliglitest  trace  of  an  anus  visi- 
ble ;  no  swelling  in  the  anal  region  took  place  whilst  the  child 
made  efforts  to  defecate.  The  scrotum  was  divided  into  two 
parts  along  the  median  line,  having  a  testicle  in  each.  The 
glans  was  in  the  perina^um  with  its  meatus,  from  which  the 
urine  passed  freely. 


312  ABDOMINAL    ARTIFICIAL    AKUS. 

M.  Diiret  made  a  fruitless  attempt  to  establish  an  artificial 
anus  in  the  periuajum,  and  through  the  incision  which  he  had 
made,  lie  introduced  a  sound,  but  no  rectum  could  be  felt. 
Twenty-four  hours  afterwards  the  case  w^as  considered  des])e- 
rate,  the  cliild's  abdomen  was  distended,  its  extremities  ci)h], 
and  there  was  constant  vomiting,  and  every  thing  indicating 
that  unless  soon  relieved,  it  must  inevitably  perish.  Duret,  to 
save  the  life  of  the  child  if  possible,  determined  to  establish 
an^  artiticial  anus  in  the  abdomen.  But  before  performino; 
this  operation  on  the  living  ease  before  him,  he  practiced 
Calliseii's  method  on  tlie  dead  body  of  a  child  two  weeks  old  ; 
observing,  however,  that  he  W(mnded  the  peritonfeum,  as  the 
ascending  colon  was  attached  to  the  mesentery,  he  at  once 
determined  to  abandon  Callisen's  and  adopt  Littre's  method 
on  the  case  in  hand.  When  the  child  was  seventy-two  hours 
old,  on  a  certain  day  in  October,  1793,  Duret  performed  Lit- 
tre's operation.  An  incision  was  made  in  the  abdominal 
cavity  above  the  iliac  region,  in  the  situation  where  the  sig- 
moid flexture  of  the  colon  formed  a  swelling.  This  portion 
of  the  intestine  was  drawn  out  by  the  finger,  and  a  ligature 
was  passed  through  the  meso-colon  to  retain  it  out  of  the  ab- 
domen. An  incision  was  then  made  into  it,  an  inch  and  a 
half  long.  The  meconium  escaped  in  abundance.  The  vom- 
iting at  once  ceased,  together  with  all  the  other  alarming 
symptoms.  On  the  fifth  day  the  sutures  uniting  the  intestine 
to  the  abdominal  wall  were  removed.  On  the  sixth  day, 
however,  the  opening  in  the  intestine  an  inch  in  length,  was 
jiartially  closed  by  the  extrusion  of  the  mucous  membrane  ; 
but  on  the  seventh  day  the  child  was  well  enough  to  be  re- 
stored to  the  care  of  its  parents.  Twelve  years  after  this  the 
patient  with  his  iliac  artificial  anus  was  doing  well.  [Recueil 
Periodique  de  la  Societe  de  Medicine  de  Paris,  tome  IV. 
p.  45.) 

What  is  remarkable,  this  patient,  according  to  M.  Amussat, 
was  still  living  in  1839,  having  then  survived  the  operation, 
fortv-six  years.  {Memoir e  sur  la  Possihilite  d'etaUir  mi  Anus 
artificiel  dams  Region  lombaire  sans  penetrer  dans  le  Peritoine. 
Paris:  1839.) 

Cask  CCLVII. — M.  Leveille  reports  the  following  case  in 
the  Journal  of  Desault. 

In  the  month  of  April,  1794,  M.  Desault  performed  the  op- 
eration of  Littre  upon  a  male  infant  forty-eight  hours  old.  In 
tins  child  tliere  was  no  trace  of  an  anus,  and  the  ischia  closely 
approaching  each  other,  seemed  to  be  placed,  one  upon  tli'c 
other.   Tills  eminent  surgeon,  previous  to  performing  colotomy, 


ABDOMINAL    AKTIFHTAL    ANUS.  313 

satisHed  liiinsclf  that  it  would  be  iiupo.ssil)le  to  estaldisli  tlie 
artificial  anus  in  the  pcriniieal  region.  The  child  dird  tniir 
days  after  tlie  operation.  In  tins  instanct;  Desuidt  niudc;  the 
artificial  anus  in  the  bigniuid  tlexture  of  the  colon. 

At  the  autopsy,  nieconiutn  was  found  in  the  bladder;  in 
the  posterior  wall  of  which,  and  between  the  mouths  of  the 
urett'rs  an  oix'uing  was  soon,  about  the  diameter  of  a  nicdinm 
sound,  leading  to  the  lower  end  of  the  intestine  which  was 
closed  in  every  direction.  What  distance  this  was  from  the 
])erimTeum  we  are  not  told.  {Journat  de  Chinorgie.  tome 
IV.  p.  2iS.     ParU:  1794.) 

Case  CCLVIII.— M.  Yoisin,  of  Versailles,  in  1789  per- 
formed the  operation  of  Littre  upon  a  child  having  an  imper- 
forate anus.  The  result  of  this  case  is  not  known,  never  hav- 
ing been  published.  It  w^as  doubtless  fatal,  or  it  would  have 
been  reported.  {Fine's  Memolre  de  la  tSocietede  Medicine  de 
Montjjellier.     tome   VI.) 

Cask  CCLIX. — M.  Desgranges  in  1800  performed  colotomy 
after  the  method  of  Littre,  in  the  case  of  a  little  girl  four  years 
old,  in  which  the  rectum  opened  into  the  vagina.  Eight 
months  after  the  operation,  Desgranges  wrote  to  Fine  that  he 
had  been  perfectly  successful,  and  that  his  little  patient  was  in 
good  health,  but  that  a  part  of  the  faeces  still  passed  by  the 
vaginal  anus,  and  that  the  artificial  anus  in  the  abdomen  had 
to  be  constantly  dilated  with  a  plug  to  prevent  it  from  com- 
pletely closing,  which  it  had  the  strongest  disposition  to  do. 
(  Voir  le  second  memoire  sur  V enterotomie par  Fine^  dans  leQ^ 
■volume  des  Annales  de  la  Societe  de  Montpellier.) 

In  this  instance  Desgranges  to  avoid,  as  he  thought,  the  dif- 
ficulties attending  the  vaginal  anus,  determined  to  establish 
at  once  the  artiticial  one  in  the  abdomen,  intead  of  in  the  per- 
inseum,  imagining  that  by  this  proceeding  he  could  the  more 
easily  get  rid  of  the  vaginal  one,  as  all  the  fsecal  matter  would 
necessarily  pass  through  the  abdominal  anus ;  consequently 
that  the  vaginal  one  would  soon  close  voluntarily. 
In  this,  however,  he  was  much  disappointed,  for  the 
faces  continued  to  pass  through  the  vaginal  opening.  Indeed 
his  case  was  anything  ^'- hid  perfectly  successful"  as  he  inti- 
mated in  his  letter  to  Fine.  The  abdominal  anus  was  entirely 
useless,  and  to  say  the  least  of  it,  not  any  less  inconvenient 
than  the  vaginal  one.  It  is  supposed  that  the  artificial  anus 
in  this  instance  Avas  made  in  the  sigmoid  flexure  of  the  colon. 


Sli  ABDOMINAL    AJtTIFICIAL   ANUS. 

Case  CCLX, — The  following  singular  case  of  supra-pubic 
abnormal  anus  is  mentioned  by  Voisin  of  Yersailles.  It  oc- 
curred in  a  male  child  in  whom  there  was  an  entire  absence  of 
the  rectum  and  the  colon,  the  ileum  terminating  in  an  abnor- 
mal anus  in  the  h_ypogastrium. 

This  child  was  seen  bj  M.  Voisin  some  time  within  the  year 
1802.  It  had  no  perinj^nm,  the  perinseal  raphe  terminated  in 
fi-ont  in  two  cutaneous  folds  which  seemed  to  represent  the  two 
halves  of  the  scrotum,  but  as  they  had  no  depth,  they  might 
have  been  regarded  as  the  labia  majora.  Voisin  finding  no 
trace  of  a  j^enis,  was  at  that  time  at  a  loss  how  to  decide  the 
sex  of  the  child.  The  abnormal  anus  commenced  to  contract 
on  the  seventh  day,  and  on  the  tenth,  symptoms  of  retention 
of  fajcal  matter  were  so  evident  that  Voisin  determined  to 
perform  Littre's  operation.  Tlie  child  survived  the  operation 
four  days. 

At  the  autopsy  it  was  found  that  the  j^ortion  of  the  intestine 
drawn  towards  the  outside  for  the  formation  of  the  artificial 
anus,  was  not  the  colon,  but  the  ileum  which  turned  from  the 
artificial  anus  towards  the  posterior  wall  of  the  bladder,  into 
which  it  opened  with  a  short  dilatation.  Tlie  vesical  opening  of 
the  ureters  was  closed  in  the  form  of  a  figure  7.  During  the 
life  of  the  child  the  urine  had  been  constantly  voided  by 
numerous  very  small  openings.  The  two  testicles  were  found 
in  the  abdominal  cavity,  but  both  the  rectum  and  the  colon  were 
absent.  {liecueil  Periodique  de  la  Societe  de  Medicine  de 
Paris,     tome  XXI.  p.  353.) 

This  was  the  second  case  upon  w^hich  M.  Voisin  practiced 
colotomy  after  the  method  of  Littre,  the  first  being  in  1798. 
This  liis  last  operation,  however,  cannot  be  called  colotomy.,  as 
the  ileum  was  the  intestine  opened,  the  colon  being  absent. 

Case  CCLXI. — In  the  case  of  a  male  child,  two  days  old, 
brought  to  M.  Billaunt  for  an  imperforate  anus,  that  operator 
nuide  a  puncture  in  the  periufeum,  at  the  point  where  the  anus 
ought  to  be,  but  ftiiled  to  reach  the  rectum.  M.  Duret  was 
called  in  immediately  and  practiced  colotomy  according  to  the 
method  of  Littre.  The  artificial  anus  in  this  instance,  was 
nuule  in  the  sigmoid  flexure  of  the  colon.  The  child  only 
lived  four  or  five  days  after  the  operation. 

At  the  autopsy,  the  closed  end  of  the  rectum  was  found  ad- 
herent to  the  posterior  wall  of  the  bladder,  but  having  no 
communication  with  it,  and  about  one  inch  from  the  place 
where  the  normal  aims  should  have  been. 

M.  Duret  performed  this  o|)eration  in  1809,  and  it  was  the 
second  case  upon  which  he   practiced  Littre's   operation,  the 


ABDOMINAL   AKTIFICIAL   ANUS.  315 

first,  [Vide  Case  CGLVIi\    bein^  iu  1793.     {These  inaugur- 
ale  de  Mlrieljeune.) 

Case  CCLXII. — M.  Legris,  a  distinguislied  surgeon  in  the 
navy  at  Brest,  in  January,  IS  13,  performed  tlie  ()])eration  of 
Littre  on  a  child  having  an  imperforate  anus  with  an  abnor- 
mal opening  of  the  rectum  into  tlie  urethra.  In  this  instance 
it  was  supposed  that  the  artificial  anus  was  established  in  the 
sigmoid  tlexure  of  the  colon.  Death  occurred  seventeen  days 
afterwards  from  ])eritonitis,  the  result  of  injury  of  the  parts 
through  the  carelessness  of  the  parents.  {These  inaugurale  de 
Serrand.     Montpellier :    1814.) 

Case  CCLXIIL— In  1813  M.  Serrand  de  St.  Malo  observed 
in  a  female  child  sixty  hours  old,  a  well  formed  anus,  but  the 
rectum  was  found  closed  one  inch  and  a  half  above  the  anal 
orifice.  The  solidity  of  the  substance  forming  the  obstruction  ; 
the  uncertainty  whether  the  superior  part  of  the  rectum  would 
be  found  in  the  vicinity  ;  the  probability  that  the  two  parts 
of  the  rectum  had  no  commnnication  with  eacli  other,  and  the 
extreme  weakness  of  the  child,  decided  JVI.  Serrand  not  to  at- 
tempt the  formation  of  a  perina3al  anus.  He  therefore  deter- 
mined to  practice  colotomy  according  to  the  process  of  Littre. 
Twenty-two  months  after  this  operation  the  child  still  lived, 
but  the  fourteenth  day  after  the  operation  it  presented  a  pro- 
lapsus of  the  incised  portion  of  the  intestine — "  an  inconveni- 
ence beyond  the  power  of  art  to  remedy."  Tlie  prolapsus 
increased  more  and  more,  and  caused  Serrand  to  fear  that  the 
happy  result  was  not  of  long  duration.  In  this  case  the  artifi- 
cial anus  was  made  in  the  sigmoid  flexure  of  the  colon. 
{These  inaugurale  de  Serrand.     3font2>eUier:  ISl-l.) 

Case  CCLXIY. — In  1813,  a  surgeon  of  Lyons  w^hose  name 
is  not  given  by  Serrand,  performed  Littre's  operation  on  a  child 
having  an  imperforate  anus.  The  artificial  anus  was  estab- 
lished in  the  sigmoid  flexnre  of  the  colon.  The  operation 
proved  successful.  {These  inaugurale  de  Serrand.  Montpel- 
lier:  1814.) 

CasE  CCLXV. — In  1813  a  surgeon  of  Brest,  performed 
Littre's  operation  in  the  case  of  a  female  infant  having  an 
imperforate  anus.  In  this  operation  the  ovary  was  included 
in  the  ligature  passed  through  the  mesentery.  The  result  was 
death.  In  this  instance  the  artificial  anus  was  formed  in  the 
sigmoid  flexure  of  the  colon.  {These  inaugurale  de  Ser- 
rand.) 


316  ABDOMINAL    ARTIFICIAL    ANUS. 

Case  CCLXYI. — Mr.  Freer,  of  Birmingham,  England,  in 
1815,  performed  Littre's  operation  on  an  infant  having  an  im- 
perforate anus.  An  unsuccessful  attempt  was  first  made  to 
establish  the  artificial  anus  in  the  i^erinaeal  region.  In  this 
case  the  lower  part  of  the  descending  colon  was  opened. 
After  confining  the  colon  with  one  stitch  at  each  end.  of  the 
wound,  a  longitudinal  incision  two  inches  in  length  was  made. 
The  child  died,  however,  in  three  weeks,  apparently  trom 
marasmus. 

At  the  autojisj,  it  was  observed  that  the  opened  intestine 
was  adherent  to  the  wound  in  the  abdominal  parietes,  and 
there  was  not  any  appearance  of  inflammation.  {London 
Medical  and  Physical  Journal^  Vol.  XL  V.  j)-  9.) 

Case  CCLXVIL— MM.  Miriel  Senior  and  Duret,  in  1816 
saw  a  female  child  two  days  old,  having  a  firm  obstruction  in 
the  rectum,  half  an  inch  above  a  well  formed  anus.  They  at 
once  abandoned  the  idea  of  attempting  to  open  out  the 
obstructed  canal,  because,  first  it  seemed  to  them  a  grave 
operation  to  push  the  bistoury  into  so  dangerous  a  region ; 
second,  the  occlusion  of  the  rectum  seemed  to  them  to  be 
thick,  and  they  apprehended  further  difliculties,  and  especially 
contraction  of  the  new  opening.  On  the  next  day,  M.  Miriel 
practiced  colotomy  according  to  the  process  of  Littre,  the  arti- 
ficial anus  being  made  in  the  sigmoid  fiexure  of  the  colon. 

This  patient  was  living,  and  in  excellent  health  in  1835, 
consequently  being  then  nineteen  years  old.  {These  inaug- 
urale  de  Miriel Jils.  Paris:  April  3,  1835.) 

^  Case  CCLXVIIL— In  1822  M.  Miriel  Senior,  for  the  second 
time,  performed  Littre's  operation  successfull}^  The  case  was 
that  of  a  male  child  three  days  and  a  half  old.  In  this  case, 
as  in  that  of  his  first,  the  anus  was  found  perfect,  but  the  rec- 
tum was  occluded,  one  inch  and  a  quarter  above  the  anal 
orifice.  Miriel  first  made  an  unsuccessful  attempt  to  open 
out  the  rectum  at  the  point  of  the  obstruction.  Tlie  i^atient 
was  living  thirteen  years  after  the  operation.  In  this  case  as 
in  the  first,  the  artificial  anus  was  established  in  the  sigmoid 
flexure  of  the  colon.     {TJiese  citee.) 

Case  CCLXIX. — In  1823,  M.  Miriel  Senior  saw  a  male 
child  six  days  old,  in  whom  the  anus  was  absent,  but  at  the 
])lace  which  the  anus  should  have  occupied,  there  was  found 
a  cutaneous  excrescence  of  firm  consistency,  inclining  toward 
the  left  side  of  the  perineal  raphe.  The  urine  did  not  pre- 
sent any  mixture  Avitli  fyecal  matter.      Miriel  first  attemjjted 


ABDOMINAL    AKTIFICIAL    ANUS.  317 

to  ostablirtli  the  urtiiicial  aims  in  tlie  anal  roii:;ion,  hy  attack- 
in"^  the  perin;enni,  iirst  witli  the  bistoury,  and  then  with  the 
trocar,  but  without  success.  He  tlien  ])ert'ornie(l  IJttre's 
operation,  and  liis  little  i)atient  survived  it,  two  years  and 
three  nionths. 

At  the  autopsy,  it  was  found  that  the  rectum  presented  the 
appearance  of  a  funnel,  with  its  brim  u])permost,  whilst  the 
narrow  beak  adhered  to  tlie  left  side  of  the  posterior  wall  <»f 
the  Idadder,  terminated  in  a  luird  aiul  closed  extremity,  two 
inches  h)n<^,  and  united  to  the  cutaneous  wall  of  the 
periimeum. 

M.  Miriel  was  of  opinion  that  the  death  of  this  child  was 
independent  of  the  artificial  anus,  but  says  himself,  that  at  the 
autopsy  he  found  the  colon  intlamed.  In  this  case  tlie  artifi- 
cial anus  was  formed  in  the  sigmoid  flexure  of  tlie  colon. 
This  made  the  third  case  upon  which  M.  Miriel,  Senior,  per- 
formed Littre's  operation.     {These  inaugurale  de  Miriel  jils.) 

Case  CCLSX. — In  the  case  of  a  child,  having  an  imperfo- 
rate anus,  as  described  by  JA'^QY^{devitus  fahriav primitivw^ 
intestini  ■recti  et  orlficu  ani.,  these,  inaugurcde  de  Wurtshourg, 
1826.)  Textor  after  having  in  vain  attempted  to  establish  tJie 
artificial  anus  in  the  perinseum,  made  it  in  the  abdomei 
according  to  the  method  of  Littre.  Eight  days  after  this  oper- 
ation the  child  died. 

At  the  autopsy  the  blind  end  of  the  rectum  was  found 
greatly  distended  with  meconium,  and  projecting  far  to  the 
front  part  of  the  pelvic  cavity. 

Case  CCLXXI. — Schlagintweit  reports  the  case  of  a  child 
having  an  imperforate  anus,  and  in  whom  there  was,  in  the 
vicinity  of  the  closed  anus,  an  elevation  of  the  skin  in  tlie 
form  of  a  crest.  In  this  case  the  rectum  adhered  to  the  bladder 
and  terminated  in  a  closed  and  pointed  extremity  which  rested 
upon  the  cocyx.  Schlagintweit  first  attempted  to  establish 
the  artificial  anus  in  the  periuseum,  and  only  abandoned  the 
attempt  after  having  penetrated  in  vain  one  inch  deep  through 
an  incision,  extending  from  right  to  left,  nine  lines  long.  He 
then  established  an  iliac  artificial  anus  in  the  sigmoid  fiexure 
of  the  colon  according  to  the  method  of  Littre.  {La  These 
hiaugurale  de  Ottinger  sur  les  Imperforations  de  Vanus. 
Munich :  1826.) 

Case  CCLXXH. — M.  Bizet,  in  1830,  saw  a  male  child 
having  an  imperforate  anus.  He  made  an  incision  in  the  per- 
inceuni   toward   the   rectum,  but  failed   to   reach  that  organ. 


318  abdom:inal  artificial  anus. 

He  then  performed  the  operation  of  Littre,  and  formed  the 
artificial  amis  in  the  sigmoid  flexure  of  the  colon.  The  child 
died  one  month  after  the  operation,  probably  from  the  effects 
of  indigestion. 

At  the  autopsy  it  was  found  that  the  rectum  was  com- 
pletely wanting  ;  and  that  tlie  inferior  extremity  of  the  colon 
was  continued  by  a  fibrous  cord  attached  to  the  posterior  wall 
of  the  bladder.     {These  inaugurale  de  Miriel  jils.) 

Case  CCLXXIII.— M.  Bizet  within  the  same  year  (1830,) 
again  performed  Littre's  operation.  1  he  case  was  that  of  a 
cliild  four  days  old,  presenting  an  imperforate  anus.  The 
child  died  on  the  day  following  the  operation.  M.  Bizet  in 
this  case,  as  in  his  first,  made  the  artificial  anus  in  the  sigmoid 
flexure  of  the  colon.     {These  citee.) 

Case  CCLXXIY.— M.  Ouvrard,  of  Angers,  in  1830,  per- 
formed Littre's  operation  on  a  female  infant  two  days  old.  In 
this  case  no  anus  was  visible.  It  is  supposed  that  the  artificial 
anus  was  established  in  the  sigmoid  flexure  of  the  colon.  The 
child  died  suddenly.  {Lancdte  Ft'ancaise^  tome  11.,  j>.  99. 
Paris :  1837.) 

Case  CCLXXY. — On  an  evening  in  March,  1835,  a  male 
child  three  days  and  a  half  old,  was  brought  to  Klewitz  at 
Colberg.  This  child  since  its  birth  had  passed  nothing  from 
its  bowels,  the  anus  being  imperforate ;  its  abdomen  was 
greatly  distended  and  painful  upon  pressure  j  it  was  very 
feeble  and  jaundiced,  nursed  but  little  and  passed  a  great 
deal  of  dark  colored  urine.  He  at  once  attempted  to  form  a 
perinaeal  artilicial  anus,  but  without  success,  after  having 
penetrated  with  the  bistoury  two  inches  in  depth  in  the  per- 
inteuin,  and  then  plunging  a  trocar  equally  without  effect,  an 
inch  deeper  still.  Klewitz  then  without  any  surgical  assistant 
and  by  candle  light,  established  an  iliac  artificial  anus  in  the 
sigmoid  flexure  of  the  colon,  according  to  the  process  of  Lit- 
tre, which  was  successful.  The  child  survived  the  operation 
two  years  and  ten  months,  having  died  of  scrofula. 

At  the  auto})sy  it  was  discovered  that  the  rectum  passing 
doA^n  to  the  middle  of  the  pelvic  cavity,  behind  the  bladder, 
presented  a  dilatation  about  the  size  of  a  pullet's  cgg^,  in 
which  was  enclosed  a  clayey  concretion  :  this  being  removed 
it  was  found  that  the  rectum  opened  into  the  bladder  close 
behind  the  internal  opening  of  the  urethra.  The  left  kidney 
and  the  left  ureter  were  absent.     {Gazette  de  Berlin.     April 


ABDOMINAL    ARTIFICIAL    AND8.  319 

29,  1835.     Also,  Tiingel.  Uher  KanstUche  Afterl'dduny.     S. 
62.  Kiel.  1853.) 

Cask  CCLXXVI. — M.  Roux  in  1839  saw  a  child  in  wlioiii 
there  was  not  the  slightest  trace  of  an  anns.  In  this  case 
Roux  established  an  artificial  anus  in  the  siijinoid  flexure  of 
the  colon,  after  the  process  of  Littre.  Tiie  child,  however, 
died  in  two  hours  after  the  operation. 

At  the  autopsy  they  found  the  cul-de-sac  of  the  rectum 
distended  with  nieconiuni,  and  distant  only  half  an  inch  from 
the  perinjiBum.  [Gezette  des  Ilopltaux  de  Paris.  Annee 
ISll.     No.  IT.) 

Cask  C'CLXXVIL — Some  tiiye  within  the  year  1846,  Dan- 
zel  of  Hamburg  was  called  to  see  a  child  three  days  old, 
which  had  passed  nothing  from  its  bowels  since  its  birth,  an(l 
which  vomited  occasionally.  Otherwise  the  child  a])peared 
well.  Its  anus  was  normal,  but  in  the  rectum  at  the  iieiglit 
of  the  little  linger  appeared  an  obstrnctiun  which  resiste<] 
both  the  linger  and  a  small  bougie.  On  the  following  day 
the  child  vomited  meconium,  yet  with  this  exception  it  still 
did  well.  In  order  to  overcome  the  obstruction,  and  if  pos- 
sible to  open  a  passage  for  the  fseces,  Danzel  introduced  on 
his  linger  a  sharp-pointed  bistoury  up  to  the  point  of  obstruc- 
tion, and  tirmly  pushed  it  in  the  direction  of  the  rectum  as 
high  as  tiie  promontory  of  the  sacrum.  No  meconium, 
however,  followed  the  withdrawal  of  the  instrument.  Dan- 
zel now  determined  to  establish  an  abdominal  artilicial  anus 
in  the  left  iliac  region  according  to  the  method  of  Littre. 
This  operation  he  at  once  executed,  establishing  the  artificial 
anus  in  the  sigmoid  flexure  of  the  colon  ;  but  on  the  eighth 
day  tlie  child  died. 

At  the  autopsy  it  was  found  that  the  rectum  and  the  colon 
were  entirely  empty  and  conti-acted,  and  that  a  complete 
obstruction  existed  in  the  caecum  which  together  with  the 
small  intestines  was  greatly  distended.  No  evidence  what- 
ever of  inflammation  was  discovered.  The  rectum  was  not 
closed  as  Danzel  had  imagined,  but  simply  a  fold  of  its 
lining  membrane  had  arrested  the  finger  and  the  bougie,  and 
thus  deceived  him  as  to  the  true  character  of  the  case.^  The 
cause  of  death  was  obvious.  Had  the  artificial  anus  been 
made  in  the  csecum,  the  probability  is  that  the  child  would 
have 'been  saved.  {[laser's  Archiv.  Band.  IX.  Heft.  3.  S.  28-1:.) 

Case  CCLXXVIII. — The  following  case  of  imperforate 
anus  and  rectum  is  reported  by  Walter  F.  Atlee,  M.D.,  of 
Philadelphia.     The   infant  was  subjected  to  Littre's    opera- 


320  ABDOMINAL   ARTIFICIAL   ANUS. 

tion  by  tlie  able  and  distingnisbed  M.  Nelaton,  of  the  Clini- 
cal Hospital  of  tbe  Faculty  of  Medicine  of  Pai'is: 

"In  April,  1854,  a  cbild,  new-born,  was  brougbt  to  tbe 
bospital,  as  liaving  no  anus,  from  iniperforation  of  tbe  rec- 
tum, or  absence  of  tbat  intestine. 

"  M.  JSTclaton  establisbed  an  artificial  anus  in  tbe  left  iliac 
tossa.  In  performing  tbe  operation,  tbe  integuments  were 
divided,  tben  tbe  muscles  one  after  tbe  otlier ;  tbe  perito- 
naeum, tbus  exposed,  was  opened,  and  tbe  intestine  was 
drawn  out  by  tbe  linger,  and  fastened  to  tbe  opening  in  tbe 
abdominal  walls  by  means  of  a  tbread.  Tbe  intestine  was 
tben  opened,  freed  of  tbe  matters  it  contained,  and  tbe 
wound  dressed  by  cbarpie,  and  a  loosely-applied  bandage 
placed  around  tbe  body.  Tbe  cbild,  bowever,  died  in  tbe 
afternoon."  {Clinical  Lectures  on  Surgery.  By  M.  Nelaton. 
From  Notes  taken  hy  Br.  Atlee.  Chap.  XIX.  jp.  588.  JPhila- 
delphia:  1855.) 

Case  CCLXXIX. — Tbe  following  case  is  reported  by  M. 
Godard,  of  Paris,  France,  as  alluded  to  in  Cask  CLXXIV., 
wliicb  see. 

"Alpbonse  Eugene  was  born  on  tbe  first  of  April,  1855, 
and  bis  motber  sbortly  after  observed  tbat  the  cbild  had  wo 
anus.  On  tbe  third  of  April,  when  be  was  two  days  old,  his 
motber  sent  him  to  tbe  Hospital  Necker,  hall  of  Saint  Cecile, 
under  tbe  direction  of  Professor  Natalis  Guillot.  Tbe  same 
day  M.  Lenoir,  es]3ecially  called  into  this  case,  made  an 
incision  in  the  perinseum,  and  tben  plunged  a  trocar  in  tbe 
direction  of  the  rectum,  hoping  to  reach  and  to  open  its  dila- 
ted extremity.  As  he  did  not  succeed  by  this  method,  he 
performed  tbe  operation  of  Littre.  The  child  immediately 
evacuated  tbe  meconium  through  tbe  wound,  and  his  con- 
dition was  greatly  improved,  ai-Td  continued  satisfactory  dur- 
ing five  days.  On  the  sixth  day  after  the  operation  he  ap- 
peared worse,  and  on  the  eleventh  of  April,  three  days  later, 
he  died. 

Tbe  urine  showed  a  mixture  of  fgecal  matter. 

The  autopsy  was  made  on  the  tAvelfth  of  April,  and  gave 
the  following  results. — Tbe  peritonaeum  investing  the  pelvic 
viscei*a  exhibited  the  most  intense  inflammation.  At  tbe  left 
of  the  bladder  there  was  a  large  abscess,  which  had  pushed 
that  organ  out  of  its  natural  position.  The  inferior  portion  of 
the  sigmoid  flexure  of  the  colon  and  the  superior  portion  of 
the  rectum,  adhering  and  united  by  numerous  false  mem- 
branes, were  drawn  into  tbe  artificial  anus,  which  was  situ- 
ated just  above  Poupart's  ligament.     These  portions  of  intes- 


ABDOMINAL    AiniKICIAL    ANUS.  321 


tine  presented  u  dark  viok-t  hue  from  wliicli  ini^lit  I)e  liil'erred 
great  vjiscuhirity.  The  rectum  descended  from  ;il>()ve  <ht\vu- 
wjird,  and  from  left  to  right.  Behind,  it  corresponded  to  fht- 
suci'um,  l)eing  united  to  it  l)y  numerous  librous  adhesions;  in 
front  it  extended  to  the  bhuhku-,  l>eing  separated  from  it  by 
the  peritomeal  cul-de-sac.  On  the  left,  the  rectum  touched 
an  extended  abscess  which  separated  it,  like  the  bladder,  from 
the  walls  of  the  pejvic  cavity  and  crowded  it  entirely  out  of 
position.  This  abscess  opened  beneath  the  rectum  ;  it  appeared 
to  result  from  the  inilamniation  of  the  cellular  tissue  of  the 
pelvic  cavity,  and  was  doubtless  the  effect  of  the  punctures 
made  with  the  trocar  in  that  region.  On  the  right  side  of 
the  rectum  there  was  nothing  observed  worthy  of  note.  The 
inferior  extremity  of  the  rectum  terminated  in  the  form  of  a 
sack,  situated  on  a  level  with,  and  behind  the  prostate,  about 
one  incli  and  three  eighths  from  the  point  of  the  perinaium  in 
which  the  puncture  was  made.  On  the  anterior  wall  of  the 
rectum,  this  sack  presented  the  oi'iiice  of  a  small  canal,  three 
eighths  of  an  inch  in  length,  which  passed  under  the  pros- 
tate and  opened  into  tlie  urethra  in  front  of  the  veru  mon- 
tanum.  That  part  of  the  urethra  situated  in  front  of  this 
opening  was  dilated  in  bottle  form,  and  of  sufficient  size  to 
contain  a  large  pea,  whilst  the  vesical  end,  or  that  part  of  the 
urethra  situated  behind  the  abnormal  opening,  was  on  the 
contrary  singularly  narrow.  {Gazette  Medicate  de  Paris. 
Annee  1855.  iV^o.  U.  p.  699.) 


SECTION    V. 

COMPENDIUM. 

The  following  table  will  present  in  a  compendious  and  con- 
venient form  for  reference,  the  twenty-five  preceding  cases 
reported  in  this  work,  in  which  the  operation  of  M.  Littre  was 
performed,  in  consequence  of  congenital  malformation  of  the 
rectum.  It  will  give  the  number,  the  operator,  the  date,  the 
sex,  the  age,  the  species  of  malformation,  the  situation  of  the 
artificial  anus,  and  the  result ;  so  far  as  any  or  all  these  facts 
are  known  to  us. 


322 


ABDOMINAL   ARTIFICIAL   ANUS. 


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ABDOMINAL   AKTIFICIAL   ANUS.  323 


SECTION     VI. 

THE  PROCEEDING  OF  LITTRE,  AS  MODIFIED  BY  PILLORE. 

The  metliod  of  M.  Pillore  is  a  modification  of  that  of  M. 
Littre,  differiiiii^  in  the  intestine  opened,  and  the  artificial 
aims  being  in  tlie  right  side.  He  recommends  the  anterior 
part  of  the  caecum  to  be  opened  tln*ongh  the  peritonaeum,  and 
the  lips  of  the  incision  in  the  intestine  to  be  fastened  by  sev- 
eral points  of  sutnre  to  the  margins  of  th<3  divided  integu- 
ment.    [  Vide  Plate  X  F,  Figures  5,  6.] 

M.  Pillore  was  induced  to  select  the  ccecum  for  the  place 
of  the  artificial  anus,  both  on  account  of  its  situation,  as  well 
as  its  forming  a  reservoir,  and  thus  preventing,  as  he  imag- 
ined, the  constant  and  involuntary  escape  of  the  fteces. 

Case  CCLXXX. — The  following  is  an  interesting  case  of 
the  success  of  M.  Pillore's  method,  and  the  only  one  on  record, 
so  far  as  my  reading  extends,  in  which  the  operation  was  per- 
formed on  account  of  congenital  malformation  of  the  rectum 
and  anus.  I  failed  to  obtain  the  German  Medical  Journal  in 
which  the  case  was  originally  reported,  and  was  compelled  to 
present  the  brief  narrative  of  it,  without  names  or  dates,  as  I 
found  it  in  the  London  Medico-Chirurgical  Review.  {No. 
LIII.  p.  230.     July,  1837.) 

"  An  infant,  three  days  and  a  half  old,  was  found  to  have 
no  anal  aperture.  The  raphe  of  the  perineum  extended  from 
the  scrotum  to  the  point  of  the  os  coccygis,  without  any  inter- 
ruption.— The  child  was  jaundiced  all  over;  the  abdomen  was 
hard  and  distended,  there  had  been  no  vomiting,  and  of  course 
no  alvine  evacuation.  It  had  taken  the  breast  repeatedly,  and 
had  also  voided  urine  several  times.  An  incision  was  made  at 
the  usual  place  of  the  anus,  and  a  trocar  was  introduced  for  at 
least  an  inch  or  more  in  the  direction  of  the  rectum ;  but 
without  any  effect.  It  was,  therefore,  deemed  unsafe  to  pen- 
etrate to  a  greater  depth ;  and  a  proposal  was  made  to  open 
the  caecum  in  the  right  iliac  region.  This  was  accordingly 
done.  An  incision  was  made  through  the  integuments  imme- 
diately in  front  of  the  anterior  superior  spinous  process  of  the 
OS  ilii,  and  when  the  peritonaeum  was  opened,  a  portion  of 
small  intestine  escaped.      This  was  replaced,  and  the  caput 


32-4  ABDOMINAL    AKTIFICIAL    ANUS. 

cneci  being  found,  an  incision  was  made  into  it.  Several  onn 
ces  of  a  consistent  meconial  matter  immediately  flowed  out, 
with  great  relief  to  tlie  symptoms.  The  progress  of  the  caso 
was  most  satisfactory  (der  Fortgangwarganzerwiinsehat) ;  co- 
pious alvine  evacuations  began  and  continued  to  escape.  On 
tlie  eighth  day  after  the  operation,  the  stitches  of  the  abdo 
minal  woimd  were  removed."  {Medizin  Zeitimg fur  He'd 
hand,  in  the  Preusse^i.) 


SECTION    VII. 

THE  PROCEEDING  OF  CALLISEN. 

Callisen,  in  preference  to  the  method  of  M.  Littre,  advised 
the  artificial  anus  to  be  formed  in  the  left  lumbar,  instead  of 
the  left  iliac  region,  doubtless  for  the  purpose  of  preserving 
the  integrity  of  the  peritonaeum.  What  is,  therefore,  gener- 
ally called  Callisen's  operation,  consists  in  opening  the  des- 
cending colon  in  the  left  lumbar  region,  without  dividing  the 
peritonaeum.  This  distinguished  surgeon,  in  order  to  accom- 
plish this  object,  directed  a  vertical  incision  to  be  made 
between  the  last  false  rib  and  the  crest  of  the  ilium,  parallel 
with  the  external  or  anterior  margin  of  the  quadratus  lumbar- 
nm  muscle. 

The  surgical  anatomy  of  the  lumbar  region  in  which  the 
operation  of  Callisen  is  to  be  performed,  I  will  give  in  the 
language  of  M.  Malgaigne.  "  The  left  lumbar  colon,"  says 
this  able. surgeon,  "  descends  at  first  in  front  of  the  loins,  from 
wdiich  it  is  separated  by  fat  only  ;  then  in  front  of  the  apone- 
urosis of  the  transversalis  abdominis  and  quadratus  lumborum, 
from  which  it  is  also  separated  by  a  thin  layer  of  fatty  tissue  ; 
below  this  aponeurosis  it  reaches  the  crest  of  the  ilium,  below 
which  it  is  no  longer  accessible  to  our  instruments.  It  is  tlien, 
between  the  loins  and  the  crest  of  the  ilium  that  we  must  seek 
it.  It  generally  corresponds  to  the  aponeurotic  groove  between 
the  quadratus  lumborum  and  transversalis,  which  itself  corres- 


ABDOMINAL   ARTIFICIAL   ANUS.  325 

ponds  to  the  external  border  of  the  comiuon  mass  of  the  sacro- 
luinbalis  and  lon<^issinius  dorsi,  easily  recognized  in  middling 
fat  subjects.  Sometimes  it  is  more  internal,  and  is  in  great 
part  concealed  by  the  quadratus  lumborum.  Yon  see  tliat  in 
any  case  it  is  on  a  level  with  the  external  edge  of  the  sacro- 
lumbalis,  and  more  deeply  under  the  external  border  of  tlie 
<[uadratiis  lumborum,  that  you  are  most  sure  to  find  it. 

The  layers  to  be  divided  are  the  skin  and  fatty  subcutane- 
ous tissue ;  beneath  this  the  latissimus  dorsi  behind,  the 
obliquus  externus  in  front ;  more  deeply  the  obliquus 
interniis,  and  then  the  transversalis ;  then  the  aponeurosis 
of  the  transversalis,  common  also  to  the  quadratus  lumborum  ; 
then  the  adipose  tissue  that  covers  the  intestine ;  and  lastly, 
the  intestine  itself.  But  here  we  have  the  most  important  re- 
lations. 

Almost  always  both  in  the  adult  and  infant,  the  left  colon  is 
deprived  of  peritonasum  in  the  posterior  third  of  its  circum- 
ference, and  especially  when  it  is  distended  by  gas  and  faecal 
matters.  But  the  space  in  which  it  is  thus  outside  the  serous 
membrane  is  very  variable  ;  and  the  more  care  must  be  taken 
not  to  wound  this  membrane,  because  it  is  here  very  thin,  and 
ahnost  adherent  to  the  aponeurosis  of  the  transversalis.  There 
is  no  certain  indication  of  this  limit.  On  the  contrary,  j>osi- 
tion  alone  informs  us  that  we  have  reached  the  colon  instead 
of  some  other  part  of  the  intestine  covered  by  the  parietal  peri- 
tonaeum. For,  of  the  three  longitudinal  bands  of  the  colon 
which  might  have  served  us  as  a  guide,  one  is  in  front,  another 
on  the  inside,  and  a  third  outside  ;  and  it  is  the  space  between 
these  two  last  that  w^e  have  to  open  behind.  Yon  see  then 
tliat  the  operation,  to  preserve  its  essential  advantage,  which 
is  the  integrity  of  the  peritonceum,  demands  a  great  firmness 
of  hand  and  great  precautions."  [Operative  Surgery.  Brit- 
tail's  translation^  p.  447.     Philadelphia :  1851.) 


326  ABDOMINAL   ARTIFICIAL   ANUS. 


SECTION    YIII, 

CASES  AND  KEMARKS. 

The  following  are  all  the  cases,  so  far  as  I  know,  in  which 
the  operation  of  Callisen  was  performed  for  congenital  malfor- 
mation of  the  anus  and  rectum. 

Case  CCLXXXI. — M.  Dupiijtren  in  his  "  Lecons  Orales," 
very  bnefly  alludes  to  the  case  of  a  male  child  having  an  im- 
perforate anus,  upon  whom  in  1818  he  performed  Callisen's 
operation,  somewhat  modified  by  himself,  and  since  then 
greatly  modified  by  M.  Amussat.  In  this  instance  Dupuytren 
established  the  artificial  anus  in  the  caecum  without  wounding 
the  peritonaeum.  The  result,  nevertheless,  was  death  from 
peritonitis.  {Lecons  Orales  de  Clinique  Chirurgicale^  tome 
III,^.  663,2  Ed'd>^ 

C^sE  CCLXXXIL— On  the  eighth  of  December,  1828,  a 
male  child  thirteen  days  old  was  brought  to  the  office  of  M. 
Bougon.  It  was  very  small  and  remarkably  thin.  This  child 
since  its  birth  had  passed  no  ftecal  matter  by  the  anus  ;  it  had 
hiccup  and  continual  vomitings.  The  skin  of  the  abdomen 
was  bluish  at  several  points  ;  an  attentive  examination  having 
discovered  no  trace  of  an  anus,  M.  Bougon  thought  best  to 
plunge  a  bistoury  into  the  place  usually  occupied  by  the  anus, 
in  order  to  assure  himself  whether  the  rectum  reached  within  a 
short  distance  of  that  point,  and  if  it  might  not  be  possible  to  re- 
establish a  natural  opening  thereby.  A  bistoury  Avith  a  straight 
blade  was  then  cautiously  pushed  to  the  depth  of  seven  or 
eight  lines  ;  no  liquid  flowed,  except  a  little  blood  ;  even  the 
cries  of  the  child  produced  no  sensation  of  fluctuation  which 
could  lead  to  a  presumption  that  the  intestinal  cul-de-sac  was 
in  the  vicinity.  M.  Bougon  then  abandoned  the  attempt  to 
make  an  artificial  anus  in  the  perinseum,  and  proceeded  in 
search  of  a  portian  of  the  colon  to  establish  an  artificial  anus 
in  the  left  lumbar  region.  For  this  purpose  he  made  a  long- 
itudinal incision  in  the  left  side  a  little  more  than  an  inch  long, 
between  the  last  false  rib  and  the  crest  of  the  ilium.  Having 
reached  the  peritonaeum,  he  detached  it  to  a  small  extent,  in 
order  to  seize  the  intestine  where  it  is  not  covered  by  the 
serous  membrane,  but  without  success.  He  then  decided  to 
open  the  peritonneum  and  seize  a  portion  of  the  colon  as  is 


AIJDOMINAL    AKTIFICIAL    ANUS.  327 

ordinarily  done.  That  intestine  was  then  bron^dit  to  flie  sur- 
face ;  it  was  opened,  and  a  guiu-elastic  canuhi  was  introduced 
into  the  cavity  which  u:;ave  vent  to  o^as  and  a  consicU'i-able 
(juantity  of  fecuU^nt  matter.  A  thread  was  used  to  maintain 
the  foreign  body  in  the  intestine. 

Sliortly  after  the  operation  the  liiccup  and  tlie  vomiting 
ceased  ;  tiie  little  patient  was  cahu  during  the  day  and  i)art  of 
the  nii»:lit. 

On  the  ninth  of  December,  about  two  o'clock,  A,  M.,  the 
child  made  plaintive  cries  and  vomited  a  sul)stance  resem- 
bling coagulated  milk.  At  the  period  of  visit  the  cries  became 
constant,  the  liiccup  returned  trom  time  to  time ;  the 
patient  sometimes  vomited  a  yellowish  liquid  which 
it  scarcely  had  the  strength  to  expel.  The  countenance 
became  altered  since  last  evening,  and  already  pre- 
sented a  cadaverous  look.  The  condition  of  the  child 
became  more  and  more  serious ;  the  vomiting  mori^ 
frequent;  little  or  nothing  passed  through  the  canula  and 
death  occurred  about  three  o'clock,  P.  M.,  twenty-eight  hours 
after  the  operation. 

Post-mortem  forty-two  hours  after  death. 

On  opening  the  abdomen  the  small  intestines  were  found  m 
their  natural  condition.  The  rectum  was  in  its  j^lace  ;  it  des- 
cended low  down  into  the  pelvis  and  terminated  about  one 
inch  from  the  natural  situation  of  the  anus,  and  the  interval 
which  separated  the  inferior  extremity  from  the  point  which 
it  ought  to  have  reached,  was  occupied  by  a  condensed  cellu- 
lar tissue  ;  all  that  portion  of  the  intestine  which  formed  th* 
rectum  was  much  distended  with  liquid  yellow  matter  ;  the 
peritonneal  surfjice  had  contracted  several  feeble  adhesions  to 
the  neighboring  intestinal  arches  ;  the  mucous  membrane  was 
inflamed  ;  the  inferior  extremity  of  the  rectum  terminated  in 
a  cul-de-sac  without  any  trace  of  an  opening.  {Lanoette  Fran- 
caise.  toine  I.  j>,  78.  Decemhre,  1828.  Also,  Gazette  des 
Jlopitaux  de  Paris.     Annee  1828.   p.  78.) 

In  this  instance  M.  Bougon  intended  to  perform  the  oper- 
ation of  Callisen,  but  as  he  not  only  opened  the  colon  but  the 
cavity  of  the  peritonaeum  also,  he  performed  that  of  Littre — 
hence  it  is  a  question,  whether  this  case  should  not  have  been 
classed  Avith  those  of  Littre. 

Case  CCLXXXIII. — ^The  following  case  is  reported  by  M. 
Godard,  as  alluded  to  in  case  CLXXIV,  which  see. 

"  Julien  Francois  Leflou  was  born  on  the  15th  of  June,  1855. 
On  the  next  day  M.  Grange,  being  consulted  by  the  mother, 
found  only  a  slight  depression  of  tlie  skin  in  the  place   of  the 


32S  ABDOMINAL    ARTIFICIAL   ANUS. 

amis.  He  made  an  incision  in  the  perinpenm,  and  tlien  plunged 
in  a  trocar,  but  failed  to  reach  the  end  of  the  rectum.  On 
the  ISth  of  June  the  child  was  received  into  the  hall  Saint 
Come  of  tlie  Hospital  des  Enfants  Malades.  M.  Guersant 
the  surgeon  of  the  hospital,  next  day  renewed  the  attempt  to 
iind  the  rectum,  but  equally  without  success.  He  then  formed 
an  abdominal  artificial  anus  after  the  method  of  Callisen. 
Shortly  after  the  operation  the  child  voided  the  meconium  by 
the  wound.  On  the  21st  of  June  inflanunation  of  the  cellu- 
lar tissue  of  the  pelvic  cavity  and  of  the  extremities,  super- 
vened, and  oii  the  23d,  at  nine  o'clock  in  the  morning,  the 
child  died.  Up  to  this  period  no  meconium  wasj^assed  inixed 
with  the  urine. 

Autopsy.  The  peritoufeum  showed  no  trace  of  inflamma- 
tion. The  artilicial  anus  was  situated  a  little  below  the  spleen. 
The  open  part  of  the  intestine  corresponded  to  the  angle 
Jbrmed  by  the  transverse  and  descending  colon.  The  rectum 
at  its  superior  extremity  was  of  normal  size,  but  as  it  descended 
into  the  pelvic  cavity,  its  diameter  diminished,  and  at  the 
upper  margin  of  the  prostate,  entirely  disappeared  ;  however, 
there  was  discovered  at  this  point  a  pipe-like  prolongation 
Avhich  passed  behind  the  bladder  and  penetrated  the  prostate  ; 
making  its  way  thence  between  the  ejaculatory  ducts,  it 
reached  and  penetrated  the  urethra  in  an  opening  covered  by 
a  thin  membrane.  This  prokuigation  extended  from  the  an- 
terior wall  of  the  rectum  and  was  lined  with  a  corrugated 
nnicous  membrane.  The  inferior  extremity  of  the  rectum 
^vas  about  one  inch  and  a  quarter  from  the  skin  of  the  perin- 
a3um,  which  with  the  subcutaneous  and  fatty  cellular  tissue 
beneath  was  five-eighths  of  an  inch  in  thickness."  {Gazette 
Medicale  de  Paris.     jVo.  44.  p.  700.) 


SECTIONIX. 

THE  PROCEEDING  OF  CALLISEN,  AS  MODIFIED  BY  AMUSSAT. 

The  principle  upon  which  Callisen's  operation  is  founded,  as 
has  already  been  observed,  is  to  establish  an  artificial  anus 
without  wounding  the  peritoneum,  by  opening  the  posterior 
third  of  the  descending  colon  in  the  left  lumbar  region,  at  that 
part  of  the  intestine  which  is  destitute  of  a  serous  investment. 


ABDOMINAL    ARTIFICIAL    AND3.  329 

The  aiuitoinj  of  the  p;irts  cuucenied  is   of  the  utmost  impor- 
tance mid  must  be  the  lirst  tiling  to  en<^agc  our  attention.     'I'lie 
most  important  point   is   tlio   reUition  which   the  desceiidiiii:: 
colon  bears  to  tlie  peritonaeum  in  the  left  lundjar  region.     In 
order  to  study  and   understand   this  well,  iVccpuMit  dissections 
upon  the  dead  body  should  be  nuide  ;  and  in  making  these  the 
body  should  always  be  opened  from  behind,  and  not  from  the 
front,  as  is  ordimirily  done.     If  the  dissection  is  made  from 
behind,  the  posterior  third  of  the  descending  colon  will  be 
found  lying  closely  against  the  ccllulo-adipose  lanunas,  which 
line  the  abdominal  wall  in  this  situation.     It  will  be  observed 
to  be  uncovered  by  peritonaeum,  and  to  have  no  loose  or  float- 
ing meso-colon ;  but  the  serous  reflexion  will  be  found  to  be 
closely  applied  to  the  abdominal  wall  on  ea«h  side  of  the  intea-f 
tine.     When,  on  the  contrary,  the  dissection  is  made  from  the 
front,  the  colon  is  always  drawn  forward,  and  in  doing  this,  a 
distinct  and  somewhat  elongated  meso-colon  is  formed  which 
does  not  normally  exist,  but  is  made  by  the  traction  of  the 
dissector  in  tearing  off  the  reflexions  of  the  peritonaeum.     It  is 
of  the  greatest  importance  to  observe  that  the  extent  of  intes- 
tine uncovered  by  peritonaeum  varies,  according  as  the  colon  is 
contracted  or  distended.     When  it  is   empty  and  contracted, 
the  peritonaeal  reflexions  come  into  very  close  apposition,  and 
nearly  overlay  the  naked  portion  of  intestine  ;  but  when  this 
is  distended  they  are  pushed  aside,  as  it  were,  and  a  broad 
expanse  of  colon  will  be  seen  to  be  uncovered  by  peritonreum. 
To  verify  this  it  is  only  necessary  to  inflate  the  colon  if  it  is 
empty  or  contracted.     The  facility  of  exposing  the  uncovered 
part  of  the  colon,  without  wounding  the  peritonaeum,  will  be 
in  the  exact  ratio  of  its  amount  of  distention. 

M.  Amussat  attributes  the  failure  of  Callisen's  operation 
on  the  dead  body,  to  the  fact  that  in  such  cases  the  intestine  is 
most  always  empty.  Those,  therefore,  who  might  wish  to  prac- 
tice the  operation  on  the  dead  subject  should  always  flrst  inflate 
the  intestine.     In  the  cases  of  congenital  malformation,  how- 


330  ABDOMINAL    AKTIFICIAL   ANUS. 

ever,  in  which  this  operation  is  required,  this  condition  of  the 
colon  does  not  obtain,  as  in  sucli  cases,  it  is  nniversally  dis- 
tended to  its  ntmost  capacity  by  meconium  and  gas,  conse- 
quently the  layers  of  the  peritonseum,  forming  its  imperfect 
mesentery,  are  so  separated,  as  to  allow  of  the  intestine  being 
readily  reached,  without  touching  the  peritonfeum. 

The  first  step  M.  Amussat  takes  to  improve  Callisen's  oper- 
ation is  to  adopt  the  transverse  instead  of  the  vertical  incision 
of  the  integuments  and  muscles,  the  advantages  of  which  he 
maintains  are,  first,  that  it  makes  the  operation  easier  and 
more  certain,  and  avoids  the  danger  of  dividing  the  lumbar 
vessels  and  nerves ;  second,  that  it  greatly  facilitates  the  dis- 
covery of  that  portion  of  the  intestine  destitute  of  peritonaeum, 
as  well  as  the  opening  of  it  without  wounding  the  periton- 
aeum ;  and  third,  that  it  enables  the  artificial  anus  to  be  estab- 
lished more  anteriorly.     {Ojncs  Citahtm.) 

M.  Amussat  besides  modifying  this  operation  in  various 
resj)ects,  has  extended  the  applicability  of  it  to  the  ascending 
colon — hence  by  his  method  it  may  be  performed  either  upon 
the  left  or  the  right  side,  according  to  the  situation  of  the  de- 
formity or  obstruction. 

Some  authorities  maintain  that  in  early  life  it  is  by  no 
means  unusual  to  find  a  kind  of  lumbar  meso-colon,  or  the 
colon  floating  and  surrounded  by  peritonteum,  like  one  of  the 
small  intestines  ;  and  that  under  such  circumstances  the  serous 
membrane  would  necessarily  have  to  be  opened,  and  the  oper- 
ation would  present  no  advantage  over  that  of  M.  Littre  ; 
consequently  they  contend  that  it  is  not  applicable  to,  nor 
should  be  performed  on  infants,  but  should  be  limited  to 
adults  alone.  M.  Amussat  on  the  contrarv,  however,  con- 
tends  that  tlie  disposition  of  the  parts  in  early  life  is  more 
favorable  for  the  operation  than  in  adults  ;  first,  because  the 
situation  of  the  lumbar  colon  is  more  fixed  or  constant  in 
early  life  ;  and  second,  because  the  kidney  forms  an  unerring 
guide  to  the  colon  which  always  lies  immediately  external  to 


ABDOMINAL    AUTIFICIAL    ANUS.  331 

that  organ.  lie  says  too,  that  the  intestine  seems  more  firmly 
adherent  to  the  parietes  of  the  abdomen  than  in  adults. 
{Troialhne  Memoir e^  ike.  In  UExaminateur  Medical  de 
Paris.  Annee  1843.  p.  216,  229.)  In  only  one  dissection 
out  of  twenty  did  M.  Amussat  find  a  lumbar  meso-colon  in 
the  infant,  and  in  that  instance  the  intestine  was  empty. 
{Bulletin  de  V Academie  Royale  de  Medicine.  30  Juin^  1842. 
p.  302.) 

The  Operation. — Every  thing  being  made  ready,  bistou- 
ries, forceps,  scissors,  crochets,  tenaculum,  sponges,  small 
curved  silver  needles,  ligatures,  and  small  canula,  the  little 
patient  should  be  placed  upon  its  abdomen  inclining  to  the 
right  side,  with  a  pillow  placed  under  the  abdomen  to  ele- 
vate it.  The  operator  will  observe  that  the  region  in  which 
the  operation  is  performed,  is  bounded  above  by  the  last 
false  rib ;  below,  by  the  crest  of  the  ilium  ;  behind,  by  the 
lumbar  spine ;  and  in  front,  by  an  imaginary  mesial  lateral 
line.  After  marking  with  ink  the  three  bony  boundaries  of 
this  oblong  quadrilateral  space,  the  operator  should  make  a 
transverse  incision  of  from  two  to  three  inches  in  length,  mid- 
way between  the  last  false  rib  and  the  crest  of  the  ilium, 
parallel  with  the  crest,  commencing  at  the  external  margin 
of  the  sacro-lumbalis  and  longissimus  dorsi  muscles.  This 
incision  must  be  continued  down,  so  as  to  divide  the  poste- 
rior margin  of  the  three  broad  muscles  of  the  abdomen,  and 
the  anterior  portion  of  the  latissimus  dorsi  and  quadratus 
lumborum.  These  muscular  layers  should  all  be  divided, 
first  across,  then  vertically,  to  aflford  a  crucial  incision,  if 
necessary,  and  the  better  to  expose  the  intestine.  All  the 
posterior  part  of  the  incision,  the  cellular  and  adipose  tissue 
which  envelops  the  kidneys  and  colon,  may  now  be  per- 
ceived. This  tissue  should  be  divided  vertically  with  caution, 
when  the  colon  will  appear  between  the  edges  of  the  incision. 
The  colon  thus  being  recognized  and  exposed,  two  threads, 
one  above  and  one  below  should  be  passed  through  its  coats 


332  ABDOMINAL   ARTIFICIAL   ANUS. 

with  a  needle,  and  by  it  should  be  drawn  to  the  middle  of 
the  external  wound,  and  in  the  space  between  the  threads,  it 
should  be  pierced  with  a  trocar,  and  after  some  of  the  meco- 
nium and  gas  has  escaped,  the  opening  thus  made,  should  be 
enlarged  by  a  crucial  incision.  It  is  highly  important  that 
the  intestine  should  be  well  drawn  forwards  before  it  is 
punctured,  fully  on  a  level  with  the  skin,  in  order  that  its 
contents  may  not  be  extravasated  into  the  loose  cellular 
tissue  around  it.  The  intestine  after  being  punctured,  and 
the  orifice  thus  made,  enlarged  by  a  crucial  incision,  should 
now  be  completely  evacuated  and  washed  out  by  injections 
of  tepid  milk  and  water  ;  after  which  the  margin  of  the  intes- 
tinal wound  should  be  fixed  by  four  hare-lip  sutures  to  the 
lips  of  the  skin  in  the  middle  tract  of  the  cutaneous  wound, 
for  the  purpose  of  preventing  the  escape  of  the  faecal  matters 
into  the  loose  cellular  tissue  of  the  region  of  the  colon,  as 
before  observed.  Tlie  anterior  and  posterior  angles  of  the 
cutaneous  incision  should  also  be  closed  by  more  or  less 
hare-lip  sutures,  according  to  their  extent,  for  the  purpose  of 
effecting  union  by  the  first  intention.  iVide  Plate  JCYI^ 
Figures  1,  2,  3.] 

The  child  should  now  be  put  to  bed  and  a  warm  poultice 
applied.  About  the  fourth  or  fifth  day  after  the  operation, 
if  all  goes  on  well,  the  sutures  may  be  removed. 

M.  Amussat  executed  Callisen's  operation  as  modified  by 
himself,  in  three  instances  of  imperforate  infants.  His  report 
of  these  cases  I  have  presented  in  full,  translated  from  the 
original.  It  will  be  found  highly  interesting  and  still  more 
fully  illustrate  his  method  of  operating.  [  Yide  Cases 
CCLXXXIV—CCLXXXV—CCLXXXVL'] 

This  operation  requires  considerable  firmness  of  hand  and 
great  precaution,  in  order  to  avoid  wounding  the  serous 
membrane,  the  preservation  of  which  is  its  essential  advant- 
age. The  most  difficult  and  the  most  perplexing  part  of  the 
operation,  however,   is  to  recognize   the   colon.     The  signs 


ABDOMINAL    ARTIFICIAL    ANUS.  333 

which  M.  Aimissat  gives,  whether  taken  separately  or  col- 
lectively are  by  no  means  diagnostic.  He  says,  for  instance, 
that  the  kidney  forms  an  nnerring  gnide  to  the  coh)i),  yet  in 
0})erating  on  his  third  case,  {(JCLXXKVI)  the  kidney  wa^ 
actually  mistaken  for  the  colon,  and  the  incision  made  into  it 
disclosed  the  mistake.  lie  himself  admits  that,  '•'■  Even  if 
the  colon  is  distended  there  are  no  sufficient  means  of  ideniifij- 
ing  it,  though  it  should  he  perfectly  laid  hareP  {Detixiiime 
Me  moire,  <]&c.) 

The  greenish  color  of  the  colon,  as  well  as  the  greater 
development  of  its  muscular  fibres,  may  aid  the  operator  to 
recognize  it.  Pressure  and  percussion  with  the  fingers,  on 
account  of  its  elastic  tumefaction,  are  excellent  means  of 
ascertaining  its  presence. 

M.  Baudens,  chief  surgeon  of  the  Military  Hospital  of 
Gros-Caillon,  objects  to  all  of  M.  Amussat's  signs.  Should 
the  colon  be  filled  wnth  faeces,  says  he,  it  would  be  hard,  and 
then  liable  to  be  confounded  wath  the  kidney  ;  should  it  be 
pliable  and  elastic,  from  being  distended  with  gas,  then  it 
could  not,  by  the  touch,  be  discriminated  from  the  small 
intestines.  He  recommends,  as  an  infallible  means  the 
employment  of  exploratory  acupuncturation.  Previous  to 
opening  what  he  supposes  to  be  the  colon,  he  introduces  an 
acupuncture  needle,  furnished  with  a  canula,  and  on  with- 
drawing the  needle,  eitlier  gas  escapes,  or  the  canula  is  soiled 
with  fieces,  if  it  has  entered  the  colon.  {Gazette  des  Ho])it- 
aux  de  Paris,  Annee  18i2.     No.  XX  VII.  p.  179.) 

M.  Baudens,  however,  with  a  much  greater  show  of  reason, 
objects  to  the  transverse  incision  proposed  by  M.  Amussat  in 
Callisen's  operation,  in  consequence  of  the  liability  of  wound- 
ing some  of  the  large  branches  of  the  genito-crural  and 
inguino-cutaneous  nerves,  and  also  that  it  exposes  too  small 
an  extent  of  the  intestine,  which  should  be  opened  by  an 
incision  at  least  one  inch  and  a  half  long,  as  otherwise  the 
anus  will  contract.     He  says,  that  M.  Amussat,  moreover,  is 


334  ABDOMINAL   ARTIFICIAL  ANUS. 

obliged  to  make  a  crucial  incision  in  the  deep  parts,  which 
perils  the  lumbar  arteries,  is  painful,  and  augments  the  extent 
of  the  wound.  In  order  to  combine  the  advantages  of  a 
vertical  and  transverse  incision  without  the  disadvantages  of 
either,  M.  Baudens  proposes  an  oblique  incision.  {Opus 
Citatum.) 


SECTION       X. 
CASES   AND  REMARKS. 

Cases  CCLXXXIY— CCLXXXV— CCLXXXVI.— In  the 

three  following  cases,  M.  Aiiiussat  performed  colotomy  after 
the  method  of  Callisen,  as  inodiiied  by  himself. 

First  Case. — "  On  the  22nd  of  January,  1842,  M.  Hippolite 
Larrey,  sent  me  a  male  infant,  born  on  the  20th  January  at 
four  o'clock,  A.  M.  On  the  next  day  after  its  birth,  seeing 
no  discharge  of  meconium,  they  discovered  that  the  child 
M-as  imperforate.  They  attempted  with  sounds,  and  even 
with  trocars  to  give  vent  to  the  meconium,  but  without 
success. 

In  other  respects  the  child  was  strong  and  well  made, 
and  the  anus  occupied  the  usual  position.  It  allowed  the 
introduction  of  sounds  and  the  fore-tinger,  but  at  about  one 
inch  deep  the  progress  of  the  finger  or  instrument  was 
arrested  by  an  obstruction,  beyond  which  no  fluctuation  was 
perceived  indicating  the  presence  of  a  distended  rectum. 

The  urine  was  slightly  affected,  but  with  no  mixture  of 
meconium  ;  the  abdomen  was  distended  hard  and  elastic,  but 
without  inequalities  or  depressions  ;  the  child  was  not  ema- 
ciated, and  the  yellow  tint  common  to  imperforate  children 
was  barely  perceptible.  Notwithstanding  the  absence  of 
fluctuation  above  the  closure  at  some  distance  from  the  anus, 
I  attempted  to  go  beyond  that,  profiting  by  the  small  opening 
already  made  with  sounds  or  trocars.  I  forced  this  opening 
with  my  finger,  and  sought  to  recognise  the  end  of  the  large 
intestine :  but  it  was  impossible  either  for  myself  or  my 
assistants  to  discern  the  least  fluctuation.  For  an  instant  I 
thought  I  felt  an  intestine  ;  but  the  sensation  was  vague,  and 
besides  I  had  reached  too  great  a  height  after  rupturing  the 


ABDOMINAL    AJ4'1TFICIAL    ANUS.  335 

cellular  tissue  of  the  pelvis  with  my  fore-finger,  to  dare  to 
attinn  that  1  had  to  do  with  an  intestine. 

Reflecting  upon  the  course  to  be  taken  in  so  embarrassing 
a  case,  I  proposed  to  establish  an  artificial  anus  in  the  left 
lumbar  region.  Tin's  proposition  liaving  been  discussed  and 
ap|)roved,  I  immediately  proceeded  to  the  operation. 

The  child  was  placed  on  its  abdomen,  a  little  inclined  to 
the  right  side,  so  that  the  left  flank  was  turned  uppermost. 
Some  folded  napkins  were  placed  under  the  right  side  to 
render  the  left  flank  more  prominent.  After  closely  exam- 
ining the  left  lumbar  region,  and  measuring  the  distance 
from  the  crest  of  the  ilium  to  the  last  false  rib,  I  marked  the 
position  of  the  vertebral  column  and  the  resistance  and  thick- 
ness of  the  tissues  of  that  region.  My  dimensions  being 
carefully  taken,  I  made  a  transverse  incision  about  two  inches 
in  length,  in  the  middle  of  the  space  comprised  between  the 
last  rib  and  the  crest  of  the  ilium.  This  flrst  incision  com- 
prised only  the  skin  and  the  cellular  tissue.  By  another 
incision  I  divided  the  thin  muscles  and  came  immediately 
upon  the  cellular  and  adipose  tissue  which  characterizes  the 
envelope  of  the  kidney  at  this  age.  I  cut  this  envelope  and 
saw  the  kidney  perfectly  naked,  and  filling  almost  the  whole 
interosseous  lumbar  space,  which  was  very  embarrassing. 
My  first  transverse  incision  not  being  sufficient,  I  made 
another,  forming  a  T  with  the  first.  I  pushed  back  the  kid- 
ney and  sought  for  the  colon.  After  nnich  uncertainty, 
thinking  I  recognized  it,  I  determined  to  seize  longitudinally 
with  a  tenaculum,  from  above  downwards  what  I  believed  to 
be  the  colon,  and  I  brought  it  towards  the  surface,  after  again 
seizing  it  wdth  another  tenaculum  which  I  inserted  in  an 
opposite  direction  and  a  short  distance  behind  the  first.  The 
organ  being  thus  firmly  fixed  and  held,  I  made  an  opening 
between  the  two  tenacula  with  the  scissors.  Immediately  we 
perceived  a  greenish  ball,  being  the  meconium  covered  with 
a  jDellicle  ;  as  soon  as  this  was  ruptured,  gas  and  meconium 
escaped.  I  then  enlarged  the  opening  a  little  above  and  below, 
and  I  seized  the  edges  w^ith  spring  forceps.  I  then  introduced 
into  the  intestine  a  canula  through  which,  by  means  of  injec- 
tions, to  dilate  the  meconium  and  to  facilitate  its  evacuation  ; 
lastly,  I  cleansed  the  wound  and  attached  the  ed^es  of  the  in- 
testinal opening  to  the  skin  by  three  jioints  ot  interrupted 
suture,  taking  care  to  draw  the  intestine  well  forward. 

The  child  was  very  weak  ;  it  had  lost  much  blood  and  it 
was  exhausted  with  pain,  and  I  must  confess  I  had  little  hope 
of  it  surviving,  nor  indeed  did  any  of  the  spectators  expect  it 
to  live. 


336  ABDOMINAL   AETIFICIAL   ANUS. 

I  advised  that  it  should  be  suckled  and  that  its  linen  should 
be  frequently  changed. 

From  day  to  day  the  condition  of  the  child  improved  ;  the 
sutures  were  detached  on  the  fourth  day  ;  the  agglutination 
of  the  edges  of  the  intestine  was  then  complete,  and  the 
opening  afforded  an  easy  exit  to  fiecal  matter. 

On  the  10th  day  after  tlie  operation,  on  examining  the  ab- 
domen which  had  diminished  in  volume,  we  observed  in  the 
left  iliac  cavity,  a  swelling  or  tumor  about  three  inches  from 
the  artificial  anus.  We  thought  that  this  sort  of  sac  was 
formed  by  the  end  of  the  large  intestine  which  terminated  at 
this  point,  instead  of  descending  into  the  pelvis. 

On  the  14th  or  the  15th  day  the  artificial  anus,  by  the 
tendency  which  it  always  had  to  contraction,  was  almost  com- 
pletely obliterated,  and  the  child  evacuated  faeces  with  difli- 
culty.  It  was  very  restless.  I  promptly  dilated  tlie  opening, 
and  I  recommended  in  future,  tlie  daily  introduction  of  wax 
bougies  to  keep  the  opening  sufficiently  large.  In  spite  of  my 
recommendation,  the  artificial  anus  contracted  to  such  a  de- 
gree, that  on  the  8th  of  March,  I  was  obliged  to  force  an  open- 
ing with  sounds  and  dilute  by  injections  the  faecal  matter 
which  liad  accumulated.  Afterwards  the  child  was  very  sick. 
Seeking  to  account  for  the  obstacle  which  had  formed  a  second 
time  to  obstruct  the  passage  of  fsecal  matter,  I  perceived  that 
the  wax  bougie  hitherto  used  had  become  too  short,  and  that 
it  dilated  only  one  half  of  the  i)a?sage ;  the  other  half  had 
contracted  on  itself  and  only  afforded  vent  to  the  more  liquid 
portion  of  the  faeces. 

After  this  dilatation  was  kept  up  by  the  introduction  of 
sounds  the  whole  length  of  the  artificial  anus,  and  from  time 
to  time  with  a  sponge  prepared  with  pack  thread,  and  no  fur- 
ther accident  occurred. 

Tlie  description  of  this  case,  which  I  do  not  read  in  full,  in 
order  to  spare  the  valuable  time  of  the  Academy,  proves  a 
complete  success  attained  by  the  establishment  of  an  artificial 
anus  in  the  left  lumbar  colon,  without  ojjening  the  peritonaeum, 
of  a  new  born  child. 

In  this  child  the  normal  anus  was  well  formed,  but  it  did 
not  communicate  with  tliat  portion  of  the  rectum  coutainiiig 
the  meconium,  and  in  spite  of  the  attempts  made  to  ascertain 
the  presence  of  this  intestine  above  the  closure,  I  could  not 
recognise  it  at  all.  I  was  therefore  forced  to  make  an  anus  in 
the  lumbar  region. 

1  would  remark  that  the  life  of  the  child  was  twice  endan- 
gered by  contraction  of  the  lumbar  anus.     It  is  therefore  in- 


AP.DOMINAL    ARTIFICIAL    ANUS.  337 

dispensable  in  tliis  and  all  similar  cases,  to  keep  up  tliis  artifi- 
cial passai^e  with  Itoiio-ies  of  wax  or  _i;inn  clastic. 

It  is  probable  that  the  intestine  terniinatt's  in  the  left  iliac 
cavity  above  the  })elvis  ;  for  when  tlie  cliild  cries  or  makes 
unusual  effort  there  is  seen  au  evident  tumor  in  that  re<;ioii. 
Is  this  disposition  favorable  to  the  ]>lan  of  operation  ]n-o])os('<l 
by  M.  Klewitz  of  Colberg?  This  oj)eration  would  consist  of  the 
repression  toM'ards  the  perinajuin,  throiig-h  the  artificial  anus  of 
the  lumbar  region,  of  the  terminal  cul-de-sac  of  the  large  intes- 
tine, and  the  establishing'  an  anus  in  the  resfion  of  the 
perin^euni  or  coccyx,  in  order  to  suppress  that  of  the  lumbar 
region.  I  do  not  think  such  an  operation  practicable,  for  it 
would  expose  the  life  of  the  child  to  the  new  changes  of  a 
serious  operation. 

MM.  Breschet,  Magendie,  and  Larrey,  who  have  seen  the 
child,  have  testified  that  it  is  strong  and  well  developed. 

To-day  it  is  more  than  a  year  old;  its  health  is  as  good  as 
its  infirmity  will  allow. 

Its  life  seems  certain  so  long  as  the  artificial  opening  is 
kept  well  dilated  and  sufficiently  open,  and  in  fine,  so  long  as 
the  retention  of  the  foeces  is  avoided. 

Let  us  consider,  however,  wdiether  some  new  operation 
might  not  be  attempted  to  restore  the  normal  passage,  as  M. 
Hippolite  Larrey  has  proposed,  or  to  establish  au  artificial 
anus  in  the  tumor  as  proposed  by  Baron  Larrey. 

Without  discussing  the  possibility  of  executing  these  two 
propositions  or  the  advantages  they  might  secure,  I  tliink  it 
more  prudent  to  attempt  nothing,  in  order  not  to  compromise 
the  life  of  the  child.  We  have  only  to  prevent  the  too  great 
development  of  the  tumor,  and  especially  the  contraction  of 
the  artificial  anus. 

In  conclusion,  this  instance  is  remarkable  in  two  respects, 
the  difficulty  of  the  operation,  and  the  difficulty  of  keeping 
the  artificial  opening  dilated. 

From  these  observations,  let  us  see  what  is  to  be  done,  and 
what  is  to  be  avoided  in  such  cases.  First,  in  a  similar  or 
analagous  case,  I  would  do  what  I  did  heloio,  or  rather,  after 
havino;  introduced  a  sound  or  the  little  fino;er,  if  I  did  not  find 
a  distinct  fluctuation,  indicating  the  upper  end  of  the  mtestme, 
I  would  dilate  the  inferior  end  with  a  prepared  sponge,  to  give 
time  to  tlie  meconium  to  distend  the  end  of  the  large  intestine 
the  better  to  explore  it,  and  if  the  simple  exploration,  without 
rent,  discovered  nothing,  I  w^ould  immediately  have  recourse 
to  the  operation  in  the  left  lumbar  region. 

But  if  I  found  the  rectum  distended  with  meconium,  as 
most  frequently  hapT)ens,  instead  of  perforating  the  obstruc- 

22 


338  ABDOMINAL    ARTIFICIAL   ANUS. 

tion  as  is  commonly  done,  I  would  make  an  incision  on  the 
side  of  the  coccyx,  behind,  and  I  would  brhig  down  the  rec- 
tum to  the  skin  and  fix  it  there  by  several  points  of  suture, 
after  opening  it,  in  order  to  make  an  artificial  anus  in  this 
region,  just  as  we  do  in  the  abdomen. 

Ordiiiarily  surgeons  content  themselves  with  making  a 
puncture  with  the  trocar,  and  then  enlarging  the  opening  ; 
but  the  child  almost  always  dies.  Almost  every  one  that  I 
have  seen  operated  on,  or  that  I  have  heard  reported,  have  the 
same  result.  Death  occurs  in  these  cases,  in  consequence  of 
an  effusion  of  ftecal  matter  in  the  cellular  tissue  of  the  pelvis, 
and  because  it  is  very  difficult  to  preserve  proper  dilatation 
of  the  artificial  opening. 

Seco7id  Case. — On  Monday,  May  2ith,  1842,  a  child  was 
brought  to  me,  of  the  male  sex,  born  on  Saturday,  22d  inst., 
at  midnight.  Since  birth  it  had  passed  no  meconium,  and 
had  vomited  almost  constantly.  I  examined  the  region  of  the 
coccyx  and  found  the  anus  well  formed  ;  but  on  introducing 
my  little  finger,  it  was  arrested  at  about  one  inch  and  a  half  in 
height,  and  I  could  find  no  fluctuation  at  the  bottom  of  this 
cul-de-sac,  indicating  that  the  rectuni  distended  by  meconium, 
terminated  above  the  obstruction.  The  abdomen  was  not 
much  distended.  The  urine  was  clear  and  flowed  from  a  very 
small  opening  situated  beneath  the  gland  ;  hypospadias  there- 
fore existed  in  this  case  as  well  as  imperforate  rectum. 

Desirous  of  assuring  myself  in  the  most  positive  manner, 
that  the  extremity  of  the  intestine  did  not  terminate  immedi- 
ately above  the  closure  of  the  rectum,  which  I  could  hardly 
reach  with  my  little  finger  introduced  by  the  anal  opening,  I 
proposed  to  place  a  prepared  sponge  in  the  anus,  in  order  to 
facilitate  future  examination.  Besides,  the  child  was  very 
sti'ong  and  active,  and  I  saw  no  inconvenience  that  could  re- 
sult from  delaying  the  operation  till  the  next  day. 

The  next  day,  the  2.5th,  the  child  was  again  brought  to  me. 
It  had  continued  to  vomit  greenish  matter,  and  the  sweetened 
water  which  they  had  given  it.  The  abdomen  was  much  dis- 
tended and  elastic  ;  the  urine  had  continued  to  escape  freely 
by  the  opening  situated  beneath  the  gland.  It  was  now  highly 
necessary  to  determine  upon  some  course. 

I  renewed  the  examination  made  the  day  before,  and  came 
to  the  same  conclusion,  that  is,  that  the  end  of  the  rectum 
did  not  terminate  above  the  closure.  It  was  impossible  to 
perceive  any  fluctuation. 

After  conferring  with  those  present,  wlio  had  made  the 
same  examinations,  I  did  not  hesitate  to  ])ropose  an  operation 


ABDOMINAL   ARTIFICIAL   ANUS.  339 

ill  tlie  left  liinihar  rcf2:ioii  in  prcforcnoe  to  tliat  wliicli  T  might 
have  perfoniied  in  the  region  of  tlie  coccyx  ;  and  u[)oii  a 
review  of  all  the  reasons  I  adduced  in  favor  of  my  opinion,  it 
was  unaniniously  decided  to  open  the  colon  in  tlie  left  lumbar 
region  and  make  no  attempt  in  the  region  of  the  coccyx. 

1  then  proceeded  to  that  operation  in  presence  of  MM. 
Chains,  physician  at  St.  Maur,  who  had  received  the  child, 
Capuron,  Bauni  of  Dantzick,  Eydoux,  Genouville,  Du])re 
Latoiir,  Parnot,  Marinier,  Dufresse,  Denouette,  Porinet,  L. 
Poycr,  Filhos,  Le  Vaillant,  &c.,  &c. 

The  child  having  been  placed  on  its  right  side,  the  head 
supported  on  a  cushion,  I  began  by  assuring  myself  of  the 
position  of  the  last  rib,  the  crest  of  the  ilium,  and  the  mass 
of  the  sacro-lumbalis,  and  longissimus  dorsi  muscles ;  then  I 
marked  in  ink  the  boundaries  of  the  region  in  which  I  was  to 
operate.  Finally,  I  made  a  transverse  incision,  about  two 
inches  loner  commencing  witli  the  common  mass  of  the  sacro- 
lumbalis  and  longissimus  dorsi  muscles.  This  incision 
promptly  extended  to  the  muscles,  which  I  was  obliged  to 
cut  crucially  as  well  as  the  skin.  Quite  a  large  artery  was 
checked  by  torsion.  I  dissected  the  layers  of  the  transverse 
aponeurosis  and  reached  the  adipose  tissue  of  the  kidney.  I 
dissected  back  this  tissue,  and  caught  sight  of  the  kidney 
which  was  uncovered  for  a  part  of  its  extent  both  behind  and 
above:  I  then  saw  beyond  and  above  this  organ,  another  one 
of  a  Iwown  color,  which  seemed  to  be  the  intestine  ;  having 
seized  it  with  two  tenacula,  I  incised  it  between  the  two 
instruments  ;  but  I  found  no  cavity,  it  was  a  solid  organ  like 
the  spleen,  or  the  supra-renal  capsule  ;  it  could  not  have 
been  the  spleen  which  I  cut,  since  that  organ  is  within  the 
peritoufBum,  and  the  peritonaeum  had  not  been  opened.  I 
therefore  concluded  that  I  had  to  do  with  the  supra-renal 
capsule,  largely  developed  and  projecting  beyond  the  kidney. 
I  then  sought  for  the  intestine  below,  pushing  the  kidney 
upward  and  backward,  and  soon  after,  having  enlarged  the 
muscular  incisions,  pushed  aside  the  kidney,  the  supra-renal 
capsule  and  the  anterior  angle  of  the  kidney,  and  having 
sponged  the  bottom  of  the  wound  carefully,  I  perceived  a 
greenish  organ :  from  its  color,  position,  and  form,  and  from 
the  sensation  of  fluctuation  perceptible  to  the  touch  of  the 
finger,  I  thought,  and  so  did  some  of  my  assistants,  that  it  was 
the  descending  colon,  distended  with  meconium.  A  drawing 
of  the  lumbar  region  which  I  had  before  me  confirmed  this 
opinion,  showing  me  the  exact  relation  of  the  parts. 

Examining  then  with  minute  attention  the  intestine  in 
question,  I  was  almost  sure  it  was  the  left  lumbar  colon  with- 


340  ABDOMINAL    AKTIFICIAL    ANUS. 

out  the  peritonseuin.  I  then  fixed  two  teiiacula  in  the  walls 
of  the  intestine,  a  short  distance  apart,  and  between  the  two 
instruments  iirmly  held,  I  cut  the  intestinal  tunics  with  the 
scissors ;  gas  immediately  escaped  with  a  prolonged  whiz 
and  having  a  characteristic  odor,  and  then  meconium  passed 
in  a  continuous  jet.  To  the  great  satisfaction  of  all  present 
tlie  result  of  the  operation  was  about  to  be  attained.  The 
child  seemed  relieved  by  the  escape  of  gas  and  fsecal  matter  ; 
for  it  was  remarked  that  it  cried  much  less.  After  enlarging 
the  opening  of  the  intestine,  I  introduced  a  cannla,  which 
penetrated  deeply  in  the  direction  of  the  sigmoid  flexure  of 
the  colon  :  then  to  keep  the  incision  open,  I  put  on  its  edges 
three  artery  forceps.  Lastly,  after  injecting  several  times 
with  tepid  water,  to  tliin  the  meconium  and  favor  its  evacua- 
tion, I  lixed  the  edges  of  tlie  intestine  to  the  anterior  angle 
of  the  wound  by  five  points  of  interrupted  suture.  By  the 
easy  evacuation  of  the  meconium  the  abdomen  had  already 
diminished ;  the  child  cleaned  and  warmed  by  placing  near 
the  fire,  was  calm,  and  drank  with  avidity  of  sweetened 
water. 

The  next  day  I  received  a  very  satisfactory  account  of  the 
child  ;  the  abdomen  was  soft,  and  insensible  to  pressure  ;  it 
drinks  readily  and  exhibits  no  signs  of  suffering.  The  meco- 
nium continues  to  flow  freely  by  the  artificial  opening. 

On  the  27th  of  May,  I  visited  the  child  in  company  with 
Doctor  Chains,  physician  at  St.  Maur.  The  abdomen  had 
completely  returned  to  its  normal  condition :  the  wound  is 
open  and  of  a  pale  color,  the  intestine  is  seen  at  its  bottom  ; 
it  is  contracted,  but  it  is  so  well  fixed  in  place  by  a  process  of 
agglutination  that  the  threads  attached  only  to  the  skin 
can  be  removed  :  inflammation  of  the  mouth  which  had  given 
me  some  uneasiness,  seems  to  diminish. 

At  the  fall  of  the  sutures,  the  kidney  caused  a  hernia  in 
the  wound.  The  child  died  seven  or  eight  days  after  the 
operation. 

Autopsy  made  on  the  2nd  of  June,  1842,  at  half  past  six 
in  the  morning,  at  Saint  Maur,  in  presence  of  MM.  Filhos 
and  Chains. 

The  abdomen  is  somewhat  spotted,  and  the  edges  of  the 
wound  are  a  little  greenish. 

The  left  pleura  contains  one  or  two  spoonfuls  of  sanguina- 
lent  and  glutinous  fluid.  The  lung  on  this  side  is  hepatized 
for  two-thirds  of  its  extent  below. 

The  stomach  is  distended  with  gas  and  fluids  ;  it  also 
contains  greenish  balls  of  curdled  milk :  the  mucous  coat 
appears  healthy. 


ABDOMINAL    AKTIFICIAL    ANUS.  3-il 

The  caicuin  is  placed  beneath  the  stomach  :  it  continues 
with  the  transverse  colon,  without  any  well  defined  line  of 
(loniarcation,  after  receivin<^  as  usual  the  end  of  the  small 
intestine.  The  vermicular  ap])endix  is  attached  to  the  upper 
part  of  the  transverse  colon.  In  consequence  of  this  di.spo.si- 
tit»n  of  the  cajcum,  there  is  no  ascending  colon,  so  that  the 
right  lumbar  region  is  occupied  by  the  small  intestines  only. 
On  the  lefc,  the  lumbar  colon  follows  the  transverse  colon, 
and  preserves  its  position  and  ordinary  relations  ;  but  after  a 
passage  of  about  two  inches  it  terminates  in  nearly  a  right 
angle  ;  the  ileum  which  comes  next,  continues  almost  trans- 
versely to  the  right,  then  returns  to  the  left,  thus  describing 
an  arch  whose  extremities  are  directed  to  the  left  lumbaV 
iliac  region.  The  two  portions  of  the  intestine  forming  the 
sigmoid  flexure  are  joined  and  adherent  for  a  large  portion 
of  their  entire  length.  Finally,  the  inferior  extremity  of  the 
arch  continues  with  the  rectum,  which  preserves  all  its  nor- 
mal relations,  and  which  terminates  at  a  very  small  distance 
from  the  closure  which  hindered  the  passage  of  faecal  matter 
by  the  anus.  We  will  add  that  tlie  rectum  is  quite  dilated 
from  its  commencement  at  the  sigmoid  flexure  throuo-h  the 
greater  part  of  its  extent,  but  that  at  a  short  distance  from 
the  closure  which  separates  it  from  the  anal  portion,  it 
assumes  a  conic  form  and  occupies  a  very  small  space.  This 
disposition  sufiiciently  explains  the  want  of  fluctuation  when 
examination  was  made  during  life  by  the  introduction  of  the 
fore-finger  as  far  as  possible  into  the  anus.  In  fact,  the 
dilated  portion  of  the  rectum  not  reaching  to  the  closing 
obstruction,  only  the  conical  extremity  of  the  intestine  could 
be  touched,  in  wdiicli  there  existed  no  matter  capable  of 
afibrding  a  manifest  fluctuation. 

The  closure  which  divides  the  rectum  into  two  parts  is 
quite  thick  and  resisting,  it  is  situated  about  two  inches  from 
the  anus. 

Adhesions  exist  between  the  skin  and  the  portion  of  the 
left  lumbar  colon  wdiich  had  been  opened.  This  portion  of 
the  intestine  is  entirely  deprived  of  peritonaeum.  A  well 
marked  projection  exists  at  the  point  where  the  continuity 
of  the  canal  has  been  interrupted  by  the  formation  of  the 
artificial  anus. 

The  peritonaeum  contains  neither  serosity  nor  false  mem- 
branes, indicating  that  it  had  been  the  seat  of  inflammation. 

Third  Case.— On  the  26th  of  January,  1843,  M.  le  docteur 
Berthier  sent  me  a  male  infant,  born  the  evening  previous, 
and  who  had  not  passed  meconium.     'J  he  midwife  discovered 


342  ABDOMIN'AJL   ARTIFICIAL   AXrS. 

i  in  perforation,  but  conviuced  that  the  child  could  not  live 
more  than  twentN'-four  or  forty-eight  hoiii-s  longer,  and  that 
no  operation  conld  be  performed,  she  had  not  thought  of  an 
attempt  being  made.  She  had,  besides,  advised  the  mother 
not  to  give  it  the  breast,  in  order  to  avoid  the  secretion  of 
milk,  which,  as  she  thought,  must  soon  be  useless.  The  child 
liad  urinated,  and  the  penis  and  scrotum  were  well  formed. 
On  examination  of  the  region  of  the  anus,  perinieum,  and 
coccyx,  the  following  appeared: — First,  There  was  no  anal 
opening.  Second,  The  raphe  continued  from  the  scrotum  to 
the  sacrum,  with  no  other  interruption  than  a  depression  at 
the  normal  position  of  the  anus,  and  a  cicatrix  adhering  to 
the  sacrum  at  tlie  point  of  the  inferior  and  posterior  portion 
of  that  bone.  Third,  Tlie  space  comprised  between  the  coc- 
cyx, whose  curve  was  quite  small,  and  the  pubis,  was  quite 
small.  Fourth,  There  was  no  kind  of  fluctuation  in  the  re- 
gions indicated.  Fifth,  When  the  child  cries,  and  makes 
efforts  as  if  to  void  excrement,  the  fingers  being  applied  to 
the  anal  region,  a  sort  of  contraction  is  perceived,  probably 
indicating  the  presence  of  some  fibres  of  the  sphincter  or 
levator  ani, 

Without  doubt  an  operation  was  clearly  indicated,  and  we 
were  authorized  to  proceed  to  perform  it  at  once ;  but,  con- 
sidering on  the  one  hand  the  absence  of  fluctuation  in  the 
anal  region,  and  on  the  other  the  condition  of  the  child,  which 
was  strong  and  active,  we  thought  best  to  wait  for  the  mor- 
row, in  order  to  see  if  the  lower  part  of  the  large  intestine, 
more  and  more  distended  by  meconium,  would  not  cause  pro- 
trusion of  the  anal  region.  "We  know,  in  fact,  that  in  some 
cases,  the  eflorts  at  expulsion,  and  the  repletion  of  the  upper 
portion  of  the  imperforate  intestine,  have  enabled  us  at  the 
end  of  several  days  to  perceive  a  fluctuation  which  it  would 
have  been  impossible  to  detect  at  an  earlier  period,  the  me- 
conium not  being  then  accumulated  in  the  last  portion  of  the 
lai-ge  intestine. 

The  next  dav  the  child  was  brouo:ht  to  us.  Its  condition 
was  aggravated.  It  vomited  and  cried  incessantly ;  its  skin 
was  of  a  violet  hue,  the  abdomen  much  distended,  and  the 
h^-pogastrium,  the  penis,  and  the  scrotum  were  already  the 
seat  of  a  serious  infiltration  which  we  had  remarked  in  simi- 
lar circumstances,  and  which  with  the  violet  color  of  the  skin, 
must  necessarily  supervene  as  a  consequence  of  the  oppres- 
sion of  the  venous  circulation  caused  by  the  distension  of  the 
intestines. 

A  careful  examination  of  the  anal  region,  made  bv  us,  as 
well  as   by  MM.  Berthier  Olifie,   brothers,  Duponchel,  L. 


ABDOMINAL    ARTIFICIAL    ANUS.  343 

Boyer,  Delarne,  Duplan,  Schuster,  Grabowski,  Leffiiillou, 
Silvestre  Dii  Perron,  Roljert,  Maingault,  Alplionse  Ainnssat, 
Le  Vaillant,  <kc.,  gave  no  indication  of  fluctuation,  an<l  we 
consequently  remained  in  tlie  same  state  of  uncertainty  as  on 
tlie  day  before.  Nevertheless,  as  this  absence  of  fluctuation 
WHS  not  an  al)Solute  indication  that  the  large  intestine  termi- 
nated very  high  up  the  pelvis,  and  as  it  was  possible  that  it 
mi^jht  terminate  in  a  cul-de-sac,  or  bv  contraction  at  an  inch, 
or  an  inch  and  a  half,  more  or  less,  from  the  anal  region,  it 
seemed  that  prudence  and  the  rules  of  surgery  required  that, 
before  making  an  anus  in  the  left  lumbar  region,  every  pos- 
sible effort  should  be  made  in  the  anal  region  to  establish  an 
anus  in  the  normal  position.  I  therefore  made  a  deep  inci- 
sion with  the  bistoury  on  the  raphe,  going  even  beyond  the 
coccyx.  I  then  detached  the  point  of  the  coccyx,  in  order  to 
excise  it,  in  case  of  necessity.  I  then  cut  in  two  the  fibrous 
bands  as  they  appeared.  But  not  feeling  any  fluctuation  in- 
dicating the  presence  of  the  inferior  end  of  the  rectum,  I  de- 
liberated with  the  assistants,  and  it  was  decidetl  that  since 
the  incision  already  made  to  a  considerable  depth  had  discov- 
ered only  fibrous  tissue,  it  was  not  probable  that  we  could 
reach  the  intestine  that  way,  and  that  besides  we  ought  not 
to  continue  an  operation  which  gave  no  chance  of  success, 
and  which,  by  its  continuance,  took  away  those  belonging  to 
the  operation  in  the  lumbar  region,  to  which  we  must  have 
recou"i-se.  I  therefore  decided,  but  with  regret,  to  abandon 
this  operation,  and  make  an  artificial  anus  in  the  left  lumbar 
region. 

The  child  was  placed  on  its  abdomen,  and  an  assistant  was 
charged  to  place  one  hand  on  the  abdomen,  in  order  to  com- 
press the  intestines  and  force  the  colon  into  the  lumbar  re- 
gion. This  being  done,  the  child  was  placed  a  little  inclined 
to  the  right  side,  and  they  traced  with  ink  the  boundaries  of 
the  region  in  wkich  the  colon  might  be  met  without  the  peri- 
tonaeum. A  transverse  incision  disclosed  adipose  tissue, 
which  was  clipped  and  removed  with  the  scissors:  then  the 
muscles  uncovered  were  incised  in  their  turn.  The  wound 
was  kept  well  distended  by  M.  Boyer,  by  the  aid  of  crochets 
devised  for  separating  the 'eyelids  in  the  operation  for  strabis- 
mus. At  the  time  of  the  operation,  I  consulted  a  plate  repre- 
senting the  lumbar  region,  to  assure  myself  that  I  was  really 
proceeding  in  the  direction  of  the  intestine ;  I  then  incised 
the  quadrilateral  lumbar  space,  hoping  to  discover  the  kidney 
which  would  have  served  me  for  a  guide.  Abody  presented 
itself,  glossy  and  of  a  violet  hue,  whose  position  and  appear- 
ance made  us  suspect  it  was  the  intestine.     The  touch  gave  a 


34:4:  ABDOMINAL    ARTIFICIAL   AlfUS. 

sensation  of  fluctuation  and  elasticity  analagons  to  that  which 
would  1)6  furnished  by  the  intestine.  In  the  doubt  as  to 
identity,  the  body  was  seized  with  two  tenacnla  and  slis^htly 
incised.  1  tlien  recognized  that  it  was  the  kidney.  Direct- 
ing nny  search  farther  on,  and  guided  by  this  organ,  I  soon 
discovered  the  colon,  recognized  by  its  green  color  and  elas- 
ticity. I  fixed  into  its  walls  two  tenacula  a  short  distance 
ripart,  and  incised  the  intestine  with  scissors  between  the  two. 
Immediately  gas  escaped  with  a  whistling  sound,  and  then 
thick,  black,  and  glutinous  meconium  passed.  Two  artery 
forceps  fixed  to  the  edges  of  the  opening  just  made,  permitted 
the  meconium  to  pass  freely,  and  to  facilitate  the  evacuation, 
a  canula  was  introduced  to  break  up  the  meconium;  at  the 
same  time  light  pressure  was  made  on  the  child's  abdomen. 
Finally,  a  large  amount  of  meconium  having  passed,  the  in- 
testine T\'as  fixed  to  the  anterior  angle  of  the  skin  by  three 
points  of  interrupted  suture.  Another  suture  was  made  to 
unite  the  posterior  angle  of  the  wound  to  recover  the  kidney. 

The  child  was  then  cleansed,  and  warmed,  and  carried 
home  by  one  of  the  neighbors  of  the  mother,  a  woman  whose 
devoted  faithfulness  never  swerved  for  a  moment,  and  whose 
admirable  conduct  was  contrasted  in  a  striking  manner  with 
tiie  inhumanity  and  ignorance  of  the  midwife  Mdio  attended 
the  delivery. 

Tlie  next  day  after  the  operation,  the  child  was  in  good 
condition ;  it  sucked  with  extreme  avidity ;  the  meconium 
and  faeces  passed  readily.     It  urinated  well. 

On  the  succeeding  day,  a  considerable  prolapsus  of  the  in- 
testinal mucous  membrane  was  seen  through  the  artificial 
opening.  But  the  prolapsus  disappeared  hy  a  light  pressure 
of  the  fingers,  and  did  not  hinder  the  exit  of  fsecal  matter. 

To  jjrevent  the  increase  of  this  prolapsus,  compresses  were 
applied,  kept  in  place  with  a  bandage,  which  was  recom- 
mended to  be  continued,  taking  it  off  only  from  time  to  time 
to  afford  exit  to  faecal  matter. 

On  the  fourth  day,  the  sutures  came  away,  even  that  which 
had  been  made  in  tlie  posterior  part.  The  prolapsus  tends 
rather  to  diminish  than  to  increase.  The  condition  of  the 
child  is  very  satisfactory  ;  it  sucks  with  avidity,  and  there  is 
every  reason  to  hope  that  it  M'ill  survive."  {Troisihne  Me- 
moire,  (&c.  /  also,  L' Examinateu7'  Medical  de  Paris,  Annee 
1843,  tome  III.,  No.  XVIIL,2?p.  229,  230,  231,  232,  233.) 

Case  CCLXXXVII. — M.  Baudelocque  reports  the  case  of 
an  infant,  two  days  old,  which  had  a  natural  anus,  but  upon 
minute   examination    he   found    the    rectum   completely   ob- 


ABDOMINAL    AKTIFIUIAL   ANUS.  345 

strnctcd  about  one  inch  above  the  anus,  lie  attem))ted  to 
open  tlie  conitnunicutioii  by  incisin<^  the  mciiibraiie  tenni- 
natin<5  tlie  rectal  cul-de-sac,  as  he  had  successful Ij  done  on  a 
])revMous  occasion,  in,  as  he  thought,  a  precisely  similar  case, 
but  completely  failed  to  reach  the  meconium,  lie  tlien  de- 
termined to  practice  lumbar  enterotomy,  according  to  tlie 
])r()cess  of  Callisen,  modified  by  Amussat. 

The  child  having  been  placed  on  its  side,  Baudelocque 
made  a  transverse  incision,  an  inch  in  length,  in  the  lumbar 
region.  The  aponeurosis  of  the  external  oblirpius  was  divided, 
as  were  also  some  fibres  of  the  quadratus  lumborum,  and  the 
colon,  which  was  found  in  a  layer  of  fat,  was  then  opened. 
A  considerable  quantity  of  meconium  escaped,  and  the  in- 
testine was  afterwards  fixed  by  three  sutures.  On  the  fourth 
day  a  little  er3'si])elatous  redness  appeared  around  the  wound, 
and  the  child  became  feverish.  Leeches  were  applied,  the 
nurse  was  changed  and  the  child  at  once  recovered.  On  the 
eighth  day  after  the  operation  it  was  doing  well.  {Memoire 
de  V  Acadeniie  Royale  des  Sciences,  Paris,  Aout  et  Octobre, 
1841:.     Also,  London  Lancet,  Vol.  /.,  Fehrtiary,  1845.) 


SECTION      XI. 

APPRECIATION. 

From  a  careful  comparison  of  the  two  operative  pro- 
cedures of  Littre  and  Callisen,  together  with  their  several 
modifications,  I  am  of  opinion  that  the  preference  should  be 
given  to  the  former,  when  infants  are  the  subjects.  M. 
Baudeu's  thinks  that,  from  the  mere  fact  of  the  great  intes- 
tine being  less  developed  in  the  infant  than  in  the  adult,  the 
cellular  space  in  the  former  must  be  so  small  as  to  occasion 
great  difiiculty  in  reaching  it  without  wounding  the  perito- 
naeum, and  that  consequently  Callisen's  oj)eration  should  be 
limited  to  the  adult.     {Opus  Citatum,  p.  127.) 

M.  Amussat  himself  admits  that  his  modification  of  Cal- 
lisen's operation  would  not  be  uniformly  practicable  on  the 
infant.     "  I  am,"  says  he,  "  more  and  more  satisfied  that  the 


346  ABDOMINAL   ARTIFICIAL   ANUS. 

anatomical  dispositions  favorable  to  the  operation,  are  the 
j'ule  ;  the  reverse,  tlie  exception."  {L* Examinatcxir  Medical 
de  Paris.     Annee  1843.     Tome  III.^  p.  235.) 

The  operative  execution  of  Littre's  process  is  certainly 
much  more  simple  and  easy  than  Callisen's  ;  even  M.  Amus- 
sat  himself  acknowledges  that  his  pi'oceeding  is  greatly  more 
complicated  than  that  of  M.  Littre.     {Opus  Citatum.) 

It  is  true  that  in  Littre's  proceeding  the  peritonaeum  is 
opened,  but  this  is  by  no  means  so  grave  an  affair  as  is  gene- 
rally supposed,  taking  into  consideration  the  success  that 
usually  attends  hernial  operations.  The  operation  even  of 
Callisen  by  no  means  insures  us  against  the  occurrence  of 
peritonseal  inflammation. 

The  position,  too,  of  the  artificial  anus,  in  my  opinion,  is 
more  convenient  and  more  favorable  in  the  groin  than  in  the 
loin.  It  being  placed  nearer  the  extremity  of  the  great  in- 
testine, it  is  more  analogous  to  the  natural  anus,  and  affords 
a  better  opportunity  to  the  excrementitious  matters  of  being 
more  completely  deprived  of  all  their  nutritive  properties  be- 
fore reaching  it. 

*  To  repeat,  I  believe  finally  that,  without  absolutely  reject- 
ing either  Callisen's  or  Amussat's  method,  it  would  generally 
be  better  to  have  recourse  to  Littre's  operation  in  the  cases  of 
children. 

M.  Malgaigne  is,  however,  of  a  contrary  opinion.  He 
says:  "The  method  of  Callisen,  avoiding  the  opening  of  the 
peritonaeum,  presents  one  real  danger  less  than  that  of  Littre, 
and  should  be  adopted  at  least  as  a  general  method.  It  has 
been  deemed  as  inconvenient  to  have  the  anus  at  the  side, 
and  even  a  little  behind  ;  and  had  we  to  consider  nothing  but 
the  sexual  relations  even,  I  should  regard  it  as  a  great  ad- 
vantage not  to  have  the  artificial  anus  before."  {Opus 
Citatum^  p.  449.) 


ABDOMINAL   AKTIFICIAL   ANUS.  347 


SECTION      XII. 

THE  PROCEEDING  OF  MARTIN. 

M.  Pakis,  m  his  inaugural  thesis,  attributes  to  M.  Dubois 
the  original  idea  of  the  method  which  M.  Martin  carried  into 
practice  on  the  dead  body,  which  he  afterwards  recommended, 
and  which  now  bears  his  name.  Tiiis  operation  consists  in 
opening  the  sigmoid  flexure  of  the  colon  in  the  left  iliac 
region,  according  to  the  process  of  M,  Littre,  being  particular 
in  making  the  intestinal  incision  longitudinal  and  as  short  as 
possible.  Through  this  opening  an  exploring  instrument — a 
sound  or  a  trocar — either  with  a  proper  curve  or  flexible, 
should  be  conducted  from  above  downwards,  towards  the 
perinseum  and  natural  situation  of  the  anus,  in  order,  if  pos- 
sible, to  render  it  salient,  and  thus  furnish  the  operator  with 
a  certain  mark  by  which  to  guide  him  in  making  his  incisions 
in  the  perinseum ;  or,  even  to  push  the  instrument  entirely 
through  the  parts  which  separate  it  from  the  perinseum,  and 
thus  indicate  the  route  of  the  bistoury.  In  either  case  the  in- 
cisions are  to  be  made  down  to  the  cul-de-sac  by  the  ordinary 
method  of  forming  an  artificial  anus  in  the  perinseal  region, 
having  the  exploring  instrument  as  the  unerring  guide  to  the 
termination  of  the  intestine.  The  wound  in  the  abdomen  is 
to  be  healed  in  the  usual  manner. 

This  double  operation  of  M.  Martin  is  somewhat  similar  to 
that  which  M.  Littre  proposed.  It,  however,  exists  only  in 
theory,  as  no  surgeon,  as  far  as  my  knowledge  extends,  has 
yet  had  the  courage  and  the  rashness  to  execute  it  on  the 
living  subject. 

M.  Yelpeau  recommends  a  sonde-d-dard  to  be  introduced, 
if  possible,  through  the  pelvis,  the  arrow  of  which,  pushed  as 
far  as  the  outside  of,  and  in  the  direction  of  the  anus,  would 


348  ABDOMINAL   ARTIFICIAL    ANUS. 

become  the  conductor  of  the  bistoury  during  the  remainder 
of  the  operation.  He  considers  it  a  much  more  suitable  in- 
strument than  either  the  large  flexible  canula,  or  the  enormous 
trocar  of  M.  Martin.  {Wouveanx  Elements  de  Medicine 
Operatoire.     Tome  III.^p.^'&o.     Paris,  1S32.) 

M.  Velpeau  thinks  that  it  would  be  improper  to  proscribe, 
or  to  reject  this  operation  indiscriminately,  as  cases  might 
occur  in  which  it  might  be  found  valuable.     {Oj)us  Citatum.) 


INDEX    TO    ILLUSTKATIYE    CASES. 


(A.) 

Adair,   William,   Case  LXXI.,   p.    171.     Imperforate   rectum   above   a 

normal  anus.     Fourth  Species. 

Adriani,  Petrus,  Cases  LYII. — LYIII.,  p.  156.  Imperforation  of  the  anus 
and  rectum.     Third  Species. 

Ainsworth,  S,  F.,  Case  CCIII.,  p.  274.  Rectum  terminated  in  the  vagina. 
Sixth  Species. 

Alix  Mat,  Franc,  Case  CXLXXXV.,  p.  266.  Rectum  terminated  in  the 
vagina.     Sixth  Species. 

Amatus,  Lusitanus,  Case  CLXXXI.,  p.  265.  Rectum  terminated  in  the 
vagina.     Sixth  Species. 

Ammon,  Friedrich  August  Von,  Case  XXVII.,  p.  86.  Simple  Imperfora- 
tion of  the  anus.  Second  Species.  Case  L.,  p.  152.  Imperforation 
of  the  anus  and  rectum.     Third  Species. 

Amussat,  J.  Z.,  Cases  XLII XLV.— XLVI— CCLXXXVI.,  pp.  137— 

145 — 341.  Imperforation  of  the  anus  and  rectum.  Third  Species. 
Cases  LXXXV.— CCLXXXIV— CCLXXXV.,  pp.  183,  334,  338.  Im- 
perforate rectum  above  a  normal  anus.  Fourth  Species.  Case 
CXLIV.,  p.  248.  Rectum  terminated  in  the  bladder.  Sixth 
Species. 

Andrews,  S.  L.,  Case  XII.,  p.  73.  Preternatural  contraction  of  the  intes- 
tines.    First  Species. 

Anonymous,  Case  CCLXXX,  p.  323.     Imperforation  of   the  anus  and 
rectum.     Third  Species. 
(349) 


350  INDEX   TO    ILLUSTRATIVE    CASES. 

Arand,  Case  CLXXXVIII.,  p.  266.     Rectum  terminated  in  the  vagina. 

Sixth  Species. 
Arnott,  James,  Case  CCLVIII.,  p.  288.     Rectum  entirely  absent.     Eighth 

Species. 
Aristotle,  vide  case,  p.  226. 
Ashton,  T.  J.,  Case  VIII.,  p.  72.     Abnormal  narrowing  of  the  anus.    First 

Species.     Case  XCIV.,  p.  194.     Imperforation  of  the  rectum  above 

a  normal  anus.     Fourth  Species. 
Ayer,  Cases   XCVIII. — XCIX.,   p.    197.     Imperforation  of   the  rectum 

above  a  aormal  anus.     Fourth  Species. 

(B) 

Baillie,  Matthew,  Case  CXLI.,  p.  247.  Rectum  terminated  in  the  blad- 
der.    Sixth  Species. 

Barbout,  Antonie  Francois,  Cases  CCXII— CCXIII.,  p.  280.  Vagina 
terminated  in  the  rectum.     Seventh  Species. 

Baron,  M.,  Case  XLI.,  p.  136.  Imperforation  of  the  anus  and  rectum. 
Third  Species. 

Bartholinus,  Thomas,  vide  case,  p.  59. 

Barton,  John  Rhea,  Case  CXCVII.,  p.  268.  Rectum  terminated  in  the 
vagina.     Sixth  Species. 

Baudelocque,  A.  C,  Cases  LXXXVIII.— CCLXXXVII.,  pp.  187—342.  Im- 
perforate rectum  above  a  normal  anus.     Fourth  Species. 

Baux,  vide  case,  p.  59. 

Beauregard,  Case  CCXXVII.,  p.  285.,  Rectum  entirely  wanting.  Eighth 
Species. 

Bedford,  Gunning  S.,  Case  XIV.,  p.  78.  Occlusion  of  the  anus  by  a  mem- 
brane.    Second  Species. 

Bell,  Benjamin,  Cases  XXX. — XXXI.,  p.  126.  Imperforation  of  the  anus 
and  rectum.     Third  Species. 

Benivenius,  Anthony,  Case  CLXXV.,  p.  264.  Rectum  terminated  in  the 
vagina.     Sixth  Species. 


INDEX   TO   ILLUSTRATIVE   CASES.  351 

Bertin,  M.,  Case  C  XXXIII.,  p.  237.    Rectum  terminated 'in  the  bladder. 

Sixth  Species. 
Billard,  C.  M.,  Case  XVII.,  p.  81.     Membranous    occlusion  of  the  anus. 

Second  Species.     Case  LXXX.,  p,  180.     Imperforation  of  the  rectum 

above  a  pervious  anus.     Fourth  Species. 
Bils,  Ludovicus  de,  Case  CCLI.,  p.  292.     The   rectum  and   colon  both 

M'anting.     Ninth  Species. 
Binninger,    John  Nicol,   Case   CCXXIL,  p.  285.     The   rectum   entirely 

absent.     Eighth  Species. 
Bird,  P.  Hinckes,  Case  XCIIL,  p.   193.      Imperforate   rectum   above   a 

normal  anus.     Fourth  Species. 
Bizet,   Case    CCLXXII.,   p.    317.      Rectum    entirely  wanting.      Eighth 

Species.      Case  COLXXIII.,  p.  318.      Imperforation  of  the  anus  and 

rectum.     Third  Species. 
Bodenhamer,  William,  Cases  I — II.,  pp.  68,  69.     Abnormal  narrowing  of 

the  anus.     First  Species.     Case  XIII.,  p.  78.    Membranous    occlusion 

of  the  anus.     Second  Species. 
Bonetus,  Theophilus,  Case  CCXXIII.,  p.  285.     Rectum  entirely  wanting. 

Eighth  Species. 
Bonn,  Andreas,  Case  CXC,  p.  266.     Rectum  terminated  in  the  vagina. 

Sixth  Species.     Case  CCXXXII.,  p.  286.     Rectum   entirely  absent. 

Eighth  Species. 
Bonnet,  Aug.,  Case  CLXII.,  p.  257.     Rectum  terminated  in  the  urethi-a. 

Sixth  Species. 
Bougon,  Case  CCLXXXII.,  p.  326.     Imperforation  of  the  anus  and  rectum. 

Third  Species. 
Bravais,  Case  CLII.,  p.  256.     Rectum  terminated  in  the  urethra.     Sixth 

Species. 
Buckingham,  C.  E.,  Case  CXLV.,  p.  250.      Rectum  terminated   in  the 

bladder.     Sixth  Species. 
Burns,  Allen,  Case  CXIX.,  p.  217.     Imperforate  anus,  with  an  abnormal 

opening  in  the  vulva.     Fifth  Species. 


352  INDEX   TO   ILLUSTRATIVE    CASES. 

Bushe,  George,*Case  LXXXII.,  p.  182.  Imperforate  rectum  above  a  normal 
anus.  Fourth  Species.  Case  CXIII.,  p.  210.  Rectmn  terminated  by- 
two  extremities  in  the  perinfeum.  Fifth  Species.  Case  CCLIL,  p. 
293.     Rectum  and  colon  both  absent.     Ninth  Species. 

(C.) 
Cabot,  Samuel,  Case  XCVI.,  p.  195.     Imperforation  of  the  rectum  above  a 

normal  anus.     Fourth  Species. 
Campbell,  John  P.,  Case  XXXV.,  p.  127.     Imperfor-.tion  of  the  anus  and 

rectum.     Third  Species. 
Camper,  Pierre,  Cases  CCV.— CCVI.— CCVII.— CCVIIL— CCIX.,  p.  280. 

Ureters  terminated  in  the  rectum.     Seventh  Species. 
Carvenon,   Case  CCXLII.,  p.   287.      Rectum   entirely  absent.      Eighth 

Species. 
Caussade,  Case  CXXI.,  p.  218.     Imperforate  anus  with  an  abnormal  orifice 

at  the  vulva.     Fifth  Species. 
Cavenne,  Case  CXXXVIII.,  p.  243.     Rectum  terminated  in  the  bladder. 

Sixth  Species. 
Chamberlaine,  William,  Case  LXXII.,  p.  173.     Imperforate  rectum  above  a 

normal  anus.     Fourth  Species. 
Chonski,  Casimir  de.  Case  CXXXV.,  p.  239.     Rectum  terminated  in  the 

bladder.     Sixth  Species. 
Clark,  A.  Bryant,  Case  XCI.,  p.  191.     Imperforate  rectum  above  a  normal 

anus.     Fourth  Species. 
Colson,  A.,  vide  case,  p.  198. 
Condie,  D.  Francis,  Case  LXXXVI.,  p.  186.     Imperforate  rectum  above  a 

normal  anus.     Fourth  Species. 
Cooke,  William,  Case  v.,  p.  71.     Abnormal  coarctation  of  the  anus.     First 

Species.     Cases  CXCIV. — CXCV.,  p.  207.     Rectum  terminated  in  the 

vagina.     Sixth  Species. 
Copeland,  Thomas,  Case  LXXIIL,  p.  174.     Imperforate  rectum  above  a 

normal  anus.     Fourth  Species. 


INDEX   TO    ir.H'STRATIVE   CASES.  353 

Courtial,  Jean  Joscpli,  vide  case,  p.  198. 

Ciuvc'illiicr,  Joan,  Case  CV.,  p.  207.     linperforate  auus,  with   tlie  rectum 

terminating  by  an  abnormal  opening  just  below  the  meatus  urinaiius. 

Fifth  Species.     Case  CXL.,  p.  247.     Rectum  terminated  in  the  biail- 

dcr.     Sixth  Species. 

(D.) 

Danzel,  Case  CCLXXVII.,  p.  319.  Occlusion  of  the  rectum  above  a  nor- 
mal anus.     Fourth  Species. 

Davies,  Redfern,  Case  LIT.,  p.  154.  Imperforate  anus  and  rectum.  Third 
Species. 

De  Jessieu,  Case  CLXXVIII.,  p.  205.  Rectum  terminated  in  the  vagina. 
Sixth  Species. 

De  La  Faye,  George,  Cases  CX — CXI.,  p.  210.  Abnormal  anus  in  the 
sacral  region.     Fifth  Species. 

De  La  Marre,  vide  case,  p.  55. 

De  La  Salle,  Case  CLIII.,  p.  256.  Rectum  terminated  in  the  urethra. 
Sixth  Species. 

De  Lens,  Case  LXXVIL,  p.  179.  Occlusion  of  the  rectum  above  a  normal 
anus.     Fourth   Species. 

Delmas,  Case  CXV.,  p.  212.  Imperforatioh  of  the  anus,  with  an  abnor- 
mal opening  at  the  side  of  the  right  nates.     Fifth  Species. 

Denonvilliers,  Case  CXVI.,  p.  212.  Imperforate  anus,  accompanied  with 
an  abnormal  opening  in  one  of  the  nates.     Fifth  Species. 

Desault,  Pierre,  Case  CCLVIL,  p.  312.  Imperforate  anus  and  rectum. 
Third  Species. 

Desgenettes,  R.,  Case  CXXXIL,  p.  237.  Rectum  terminated  in  the  blad- 
der.    Sixth  Species. 

Desgranges,  Case  CCLIX.,  p.  313.  Rectum  terminated  in  the  vagina. 
Sixth  Species. 

Desormeaux,  P.,  vide  case,  p.  45. 

Devilliers,  Case  XI.,. p.  72.     Abnormal  contraction  of  the  anus.     First 

Species. 
^  23 


354  INDEX  TO   ILLIJSTKATIVE    CASES. 

Dewees,  William  P.,  vide  cases,  p.  39. 

Dieffenbach,  Johann  Friedrich,  Cases  CIII. — CIV.,  p.  206.     Imperforation 

of   the  anus,  with   an  abnormal   opening   in   the   scrotum.      Fifth 

Species.     Case  CXCIX.,  p.  271.     Rectum  terminated  in  the  vagina. 

Sixth  Species. 
Dodonaeus,  Rembertus,  Case  CLXXX.,  p.  265.      Rectum  terminated  in 

the  vagina.     Sixth  Species. 

Dubois,  Anton,  Case  CCLV.,  p.  311.    Imperforate  anus  and  rectum.    Third 
Species. 

Duges,  Anton,  vide  case,  p.  45. 

Dumas,  Case  CLXV.,  p.  258.     Rectum  terminated  in  the  urethra.     Sixth 

Species. 
Dupareque,  Cases  XX — XXI.,  p.  84.     Simple  occlusion  of  the  anus.    Second 

Species. 

Dupuytren,  M.  le  Baron,  Case  CCLXXXI.,  p.  326.     Imperforate  anus  and 
rectum.     Third  Species. 

Duret,  Cases  CCLVI. — CCLXI.,  pp.  311 — 314.     Imperforation  of  the  anus 

and  rectum.     Third  Species. 

Durr,  George  Tobie,  Case  CII.,  p.  206.     Imperforate  anus,  with  an  ab- 
normal orifice  at  the  anterior  part  of  the  perin^eum.     Fifth  Species. 

(E.) 

Edwards,  D.  0.,  Case  LXXYL,  p.  177.     Occlusion  of  the  rectum  above  a 

normal  anus.     Fourth  Species. 
Engel,  H.  T.,  Case  CCXVI.,  p.  281.    The  vagina  terminated  in  the  rectum. 

Seventh  Species. 
Engerran,  Case  LXYI.,  p.  168.     Imperforate  rectum  above  a  normal  anus. 

Fourth  Species. 
Estero,   Case   CCXXXI.,   p.    286.      Rectum    entirelj^  wanting.      Eighth 

Species. 

(F.) 

Fabricius,  Guilhelmus,  Case  CI.,  p.  206.     Occlusion  of  the  anus  with  an 
Abnormal  orifice  at  the  root  of  the  penis.     Fifth  Species. 


INDEX   TO   ILLUSTRATIVE   CASES.  355 

Fabricius,  Ilieronymus,  vide  ease,  p.  8G. 

Fenerly,  Case  XXVIII.,  p.  123.     luiperforation  of  the  anus  and  rectum. 

Third  Species. 
Fergusson,  "William,  Case  VII.,  p.  71.     Abnormal   narrowing  of  the   anal 

orifice.     First  Species.     Case  CLXXII.,  p.  201.     Rectum  terminated 

in  the  urethra.     Sixth  Species. 
Fitteau,   Case    CCLXL,   p.    287.      Rectum    entirely    wanting.      Eighth 

Species. 
Flajani,  Giuseppe,   Case   CLIV.,   p.   256.      Rectum    terminated  in    the 

urethra.     Sixth  Species. 
Fleischmann,  S.,  Case  CCXLIV.,  p.  288.    Rectum  entirely  wanting.    Eighth 

Species. 
Ford,  Edward,  Case  LXX.,  p.  170.     Imperforate  rectum  above  a  normal 

anus.     Fourth  Species. 
Forget,  C.  P.,  Case  XXXVIII.,  p.  135.     Imperforation  of  the  anus  and 

rectum.     Third  Species.    Case  LXXXIX.,  p.  180.    Imperforate  rectum 

above  a  normal  anus.     Fourth  Species. 
Fourcart,  Case  XXXVII.,  p.  133.     Imperforation  of  the  anus  and  rectum. 

Third  Species, 
Fourcade,  vide  case,  p.  56. 
Fournier,  M.,  Case  CXCIII.,  p.  267.     Rectum  terminated  in  the  vagina. 

Sixth  Species. 
Freer,  George,  Case  CCLXVI.,  p.  316.     Imperforation  of  the  anus  and 

rectum.     Third  Species. 
Friedberg,  Hermann,  Case  XLVII.,  p.  147.    Imperforate  anus  and  rectum. 

Third  Species.     Case  LXXXIV.,  p.  183.     Occlusion  of  the  rectum 

above  a  normal  anus.     Fourth  Species.     Case  CXVII.,  p.  212.     Im- 
perforation of  the  anus,  with  an  abnormal  opening  in  the  scrotum. 

Fifth  Species. 
Fristo,  Oases  CVIII— CIX.,  p.  210.    Imperforate  anus  in  each  case,  with 

an  abnormal  one  in  the  groin  of  one,  and  at  the  dorsum  of  the  penis 

of  the  other.     Fifth  Species. 


356  INDEX    TO   ILLUSTRATIVE   CASES. 

Fiirst,  Case  CLXXXIX.,  p.  266.     Rectum  terminated  in  the  vagina.    Sixtli 
Species. 

(G.) 

Gay,  G.  H.,  Case  CXLIX.,  p.  254.     Rectum  terminated   in   the  bladder. 

Sixth  Species.  , 

Giering,  Case  CCXL.,  p.  287.     Rectum  entirely  absent     Eighth  Species. 
Gilman,  Noah,  Case  CXLYI.,  p.  252.     Rectum  terminated  in  the  bladder. 

Sixth  Species. 
Goeschler,  Case  XCII.,  p.  192.     Occlusion  of  the  rectum  above  a  normal 

anus.    Fourth  Species. 
Green,  Vf.  A.,  Case  CXIV.,  p.  211.     Imperforate  anus,  with  an  abnormal 

opening  at  the  anterior  part  of  the  perinajum.     Fifth  Species. 
Gi-imaud,  vide  case,  p.  198. 
Gross,  Samuel  D.,  Case  CL.,  p.  255.     Rectum  terminated  in  the  bladder. 

Sixth   Species.     Case   CCLIII.,   p.   293.       Rectum   and   colon  both 

absent.     Ninth  Species. 
Guersant,  Cases  CLXXIV.— CCLXXXIII.,  pp.  262—327.     Rectum  termi- 
nated in  the  uretha.     Sixth  Species. 

(H.) 

Haesbert,  Case  CLXXIX.,  p.  265.     Rectum  terminated  in  the  vagina. 

Sixth  Species. 
Hartmann,  Phillipus,  Case  CLXXXIV.,  p.  266.     Rectum  terminated  in 

tlie  vagina.     Sixth  Species.     Vide  also  case,  p.  230. 
Harward,  George,  Case  CXXIL,  p.  219.     Occlusion  of  the  anus,  with  an 

abnormal  opening  in  the  labia  pudendi.     Fifth  Species. 
Heister,  Laurence,  Cases  LV — LVI.,  p.  156.     Imperforation  of  the  anus 

and  rectum.     Third  Species. 
Henkel,  J.  F.,  Case  CCXXX.,  p.  286.     Rectum  entirely  absent.     Eighth 

Species. 


INDEX    TO    ILLUSTRATIVE   CASES.  357 

Iligginson,  F.,  Case  XXXIX.,  p.  135.  Imperforate  anus  and  rectum. 
Third  Species. 

Hill,  Thomas  P.,  Case  LXTI.,  p.  150.  Imperforate  anus  and  rectum. 
Third  Species. 

Iloehstetter,  0.  F.,  Case  CLVI.,  p.  257.  Rectum  terminated  in  the  urethra. 
Sixth  Species. 

IIofTman,  Richard  K.,  Case  LXXXI.,  p.  181.  Imperforate  rectum  above  a 
normal  anus.     Fourth  Species. 

Iloltzach,  Case  CXXVI.,  p.  236.  Rectum  terminated  in  the  bladder.  Sixth 
Species. 

Houghton,  L.  W.J  Case  CXLIII.,  p.  248.  Rectum  terminated  in  the  blad- 
der.    Sixth  Species. 

Howship,  John,  Case  XVIII.,  p.  81.  Imperforation  of  the  anus.  Second 
Species.  Case  CXCVI.,  p.  267.  Rectum  terminated  in  the  vagina. 
Sixth  Species. 

Huber,  A.,  Case  CCXXXIV.,  p.  286.  Rectum  entirely  wanting.  Eighth 
Species. 

Hutchison,  Alexander  Copeland,  Case  V  ,  p.  71.  Preternatural  narrovping 
of  the  anus.  First  Species.  Case  XV.,  p.  80.  Occlusion  of  the  anas 
by  a  simple  membrane.  Second  Species.  Case  XXXVI.,  p.  128.  Im- 
perforation of  the  anus  and  rectum.  Third  Species.  Case  LXXV., 
p.  176.     Imperforate  rectum  above  a  normal  anus.     Fourth  Species. 

(J.) 

Jamieson,  James,  Case  CCXXXVI.,  p.  286.      Rectum  entirely  wanting. 

Eighth  Species. 
Jacquemin,  Case  CCXLVII.,  p.  288.     Rectum  entirely  absent.     Eighth 

Species. 
Jessen,  Johan,   Case  LXIIL,  p.  167.     Imperforate  rectum  above  a  normal 

anus.     Fourth  Species. 
Johnson,  W.  Otis,  Case  XXV.,  p.  85.    Simple  occlusion  of  the  anus     Second 

Species. 


358  INDEX   TO   ILLUSTEATIYE    CASES. 

Jones,  George  Stephens,  Case  XCVII.,  p.  196.     Imperforate  rectum  above 

a  normal  anus.     Fourth  Species. 
Jones,  James,  Cases  LX — LXI.,  p.  157.     Imperforate  anus  and  rectum. 

Third  Species.     Case  LXXXVII.,  p.  186.     Occlusion  of  the  rectum 

above  a  normal  anus.     Fourth  Species. 
"  Journal  des  Savants,^^  Case  CCXX.,  p.  282.     Vagina  terminated  in  the 

rectum.      Seventh   Species. 

(K.) 

Kirsten,  Case  CXCI.,  p.  266.     Rectum  terminated  in  the  vagina.    Sixth 

Species. 
Klein,  Christian,  Case  CCX.,  p.  280.    Ureters  terminated  in  the  rectum. 

Seventh  Species. 
Klewitz,  Case  CCLXXV.,  p.  318.    Rectum  terminated  in  the  bladder. 

Sixth  Species. 
Kretschmar,  Case  CLVII.,  p.  257.     Rectum  terminated  in  the  urethra. 

Sixth  Species. 

(L.) 

La  Coste,  Case  CXII.,  p.  210.    Imperforate  anus,  with  an  abnormal  opening 

in  the  sacral  region.     Fifth  Species. 
Latta,  James,  Cases  XXXII — XXXIII.,  p.  126.    Imperforation  of  the  anus 

and  rectum.     Third  Species. 
Lauremberg,  Case  CLXI.,  p.  257.    Rectum  terminated  in  the  urethra. 

Sixth  Species. 
Legris,  Case  CCLXII.,  p.  315.    Rectum  terminated  in  the  urethra.    Sixth 

Species. 
Lenoir,  Case  CCLXXIX.,  p.  320.     Rectum  terminated   in  the  urethra. 

Sixth  Species. 
L^veille,  Case  CCXXXIX.,  p.   287.      Rectum  entirely  absent.     Eighth 

Species. 


I 

i 


INDEX   TO    ILLUSTKATIVE   CASES.  359 

Licetus,  Fortunius,  Case  CLI.,  p.  25G.    Rectum  terminated  in  tlic  urethra. 

Sixth  .Species. 
Lieutand,   Case  XLIX.,  p.  152.     Tmperforation  of  the  anus  and  rectum. 

Third  Species. 
Littr^,  Case  C,  p.  198.    Imperforate  rectum  above  a  normal  anus.    Fourth 

Species.     Case  CCXLIX.,  p.  292.     Rectum   and   colon  both  absent. 

Ninth  Species. 
Lohmann,  Case  CCLIV.,  p.  293.     Rectum  and  colon  both  absent.     Ninth 

Species. 
Louis,   Case   CCXIV.,   p.  281.     The  vagina   terminated  in  the   rectum. 

Seventh  Species. 
Lucas,  Bennett,  Case  CXXXVI.,  p.  239.     Rectum  terminated  in  the  blad- 
der. ^  Sixth  Species. 
Ludovicus,  Case  CCXXXIIL,  p.  286.     Rectum  entirely  wanting.     Eighth 

Species. 

(M.) 

Man  tell,  T.,  Case  CXXIY.,  p.  221.     Imperforate  anus  with  an  abnormal 

opening  near  the  labia  pudendi.     Fifth  Species. 
Matani,  Ant,  Case  CCXXXV.,  p.  286.     Rectum  entirely  wanting.     Eighth 

Species. 
Martin,  De  Lyon,  Case  CCXXXVII.,  p.  287.     Rectum   entirely  absent. 

Eighth  Species. 
Martin,  vide  case,  p.  230. 
]McEvoy,  Francis,  Case  XXXIV.,  p.  226.     Imperforation  of  the  aniis  and 

rectum.     Third  Species. 
Meckel,  J.  F.,  Case  CCXXXVIII.,  p.  287.     Rectum  entirely  wanting. 

Eighth  Species. 
"  Memoires  de  Berlin,''^  Case  CCXIX.,  p.  282.     The  vagina  terminated  in 

the  rectum.     Seventh  Species. 
JNfercurialis,  Hieronymus,  Case  CLXXVIL,  p.  265.     Rectum  terminated  in 

the  vagina.     Sixth  Species. 


360  INDEX   TO   ILLUSTRATIVE    CASES. 

Merriman,  Samuel,  Case  XIX.,  p.  83.  Imperforation  of  the  anus.  Second 
Species. 

Merry,  Jean,  Cases  CCXXVIII— CCXXIX.,  p.  28G.  Rectum  entirely 
absent.     Eighth  Species. 

Miller,  Case  CXXXVII.,  p.  241.  Rectum  terminated  in  the  bladder.  Sixth 
Species. 

Miriel,  St^nieur,  Cases  CCLXVII— CCLXVIII.,  p.  .31G.  Imperforate  rec- 
tum above  a  normal  anus.  Fourth  Species.  Case  CCLXIX.,  p.  316. 
Imperforate  anus  and  rectum.     Third  Species. 

Mitchell,  S.,  Case  LI.,  p.  152.  Imperforate  anus  and  rectum.  Third 
Species. 

Monad,  Case  CVII.,  p.  210.  Imperforate  anus,  with  an  abnormal  opening 
near  the  glans  penis.     Fifth  Species. 

Moore,  E.  B.,  Case  XVI.,  p.  80.  Occlusion  of  the  anus.*  Second 
Species. 

Morgagni,  .Joan  Bapt,  Case  CXXIX.,  p.  237.  Rectum  terminated  in  the 
bladder.  Sixth  Species.  Case  CCXXIV.,  p.  285.  Rectum  entirely 
absent.     Eighth  Species. 

Motais,  vide  case,  p.  87. 

Murray,  Adam,  Case  CXXVIII.,  p.  236.  Rectum  terminated  in  the  blad- 
der.    Sixth  Species. 

Mutter,  T.  D.,  Case  CXXV.,  p.  223.  Imperforate  anus,  with  an  abnormal 
opening  just  within  the  fourchette.     Fifth  Species. 

(N.) 

Nagel,  Case  CXXIII.,  p.  221.  Imperforate  anus,  with  an  abnormal  open- 
ing near  the  lower  commissure  at  the  entrance  of  the  vagina.  Fifth 
Species.  Case  CLXXIII.,  p.  262.  Rectum  terminated  in  the  urethra. 
Sixth  Species. 

Nekton,  M.J  Case  CCLXXVIII.,  p.  319.  Imperforate  anus  and  rectum. 
Third  Species. 


INDEX    TO    ILLUSTRATIVE   OASES.  361 

(0.) 

Qlinet,  Case  CXVIII.,  j)..  217.  Imperforate  amis,  with  an  abnormal  open- 
ing near  the  vulva.     Fifth  Species. 

Orfila,  M.  P.,  Case  CCXVIL,  p.  281.  The  vagina  terminated  in  the  rec- 
tum.    Seventh  Species. 

Osiander,  Case  CXXVIL,  p.  23G.  Kectum  terminated  in  the  bladder. 
"Sixth  Species. 

Oosterdykc,  Case  CCXLIII.,  p.  288.  Rectum  entirely  absent.  Eighth 
Species. 

Otto,  Case  CCXLV.,  p.  288.     Rectum  entirely  absent.     Eighth  Species. 

Ouvrard,  Case  CCLXXIY.,  p.  318.  Imperforate  anus  and  rectum.  Third 
Species. 

(P-) 

Palmer,  Case  CCXLVI.,  p.  288.  Rectum  entirely  absent.  Eighth 
Species. 

Papendorf,  Case  CLXXXYI.,  p.  2G6.  Rectum  terminated  in  the  vagina. 
Sixth  Species. 

Parkman,  S.,  Case  XCV.,  p,  194.  Imperforation  of  the  rectum  above  a 
normal  anus.     Fourth  Species. 

Parrish,  Joseph,  Case  CXCVIII.,  p.  2G9.  Rectum  terminated  in  the  vagina. 
Sixth  Species. 

Petermann,  And.,  Case  CLXXXIII.,  p.  2G6.  Rectum  terminated  in  the 
vagina.     Sixth  Species. 

Petit,  Jean  Louis,  Cases  XXII. — XXIII.,  pp.  84 — 85.  Simple  Imperfora- 
tion of  the  anus.  Second  Species.  Case  LIII.,  p.  155.  Imperforate 
anus  and  rectum.  Third  Species.  Case  LXV.,  p.  167.  Imperforate 
rectum  above  a  normal  anus.  Fourth  Species.  Case  CCL.,  p.  292. 
The  rectum  and  colon  both  absent.     Ninth  Species. 

Pikcop,  .John,  Case  LXXXIX.,  p.  188.  Imperforate  rectum  above  a  no  r- 
mal  anus.     Fourth  Species. 


362  INDEX   TO    ILLUSTRATIVE    CASES. 

Pineo,   P.,   Case   XL.,   p.    136.     Imperforate   anus  and  rectum.     Third 

Species. 
Pinkstan,  Case  LXIX.,  p.  109.     Imperforate  rectum  above  a  normal  anus. 

Fourth  Species. 
Portal,  M.,  Case  CCXV.,  p.  281.     The  vagina  terminated  in  the  rectum. 

Seventh  Species. 
Poulletier,  Case  CLVIII.,  p.  257.     Rectum  terminated  in  the  urethra. 

Sixth  Species. 

(R.) 

Randolphe,  Case  CXLIY.,  p.  258.      Rectum  terminated  in  the  urethra. 

Sixth  Species. 
Richardson,    Case   CCXI.,   p.  280.     Ureters  terminated  in  the  rectum. 

Seventh  Species. 
Ricord,  Philip,  Case  CCL,  p.  273.     Rectum  terminated  in   the  vagina. 

Sixth  Species. 
Rochard,  Case  CXCII.,  p.  2G7.     Rectum  terminated  in  the  vagina.     Sixth 

Species. 
Roonhuysen,  Henry  Van,  Case  III.,  p.  70.     Abnormal  narrowing  of  the 

anus.     First  Species. 
Rossi,  Case  CCXVIIL,  p.  281.     The  vagina  terminated  in  the  rectum. 

Seventh  Species. 
Roux,  J.  N.,  Case  CLXVII.,  p.  258.     Rectum  terminated  in  the  bladder. 

Sixth   Species.     Case   CCLXXVI.,   p.   319.     Imperforate   anus   and 

rectum.     Third  Species. 
Ruysch,  IL,  Case  XXVI.,  p.  86.     Occlusion  of  the  anus  by  a  simple  mem- 
brane.   Second  Species.    Cases  CCXXV.— CCXXVL,  p.  285.    Rectum 

entirely  absent.    Eighth  Species. 

(S.) 
Sandan,  Van,  Case  CXXXI.,  p.  237.     Rectum  terminated  in  the  bladder. 
Sixth  Species. 


INDEX   TO    ILLUSTRATIVE   C\SE3.  363 

Samlras,  Case  LXXVIII.,  p.  179.     Imperforate  rectum  above  a  normal 

anus.     Fourth  Species. 
Saviard,  Bartholomew,  Case  XXIV.,  p.  85.  Simple  imperforation  of  the  anus. 
Second  Species.     Case  LIV.,  p.  156.     Imperforate   anus  and  rectum. 

Third  Species.     Case  CCIV.,  p.  275.     The  rectum,  together  with  the 

urethra  and  vagina,  terminated  in  a  cloaca  in  the  perinajum.     Sixth 

Species. 
Schenckius,  John,  Case  LIX.,  p.  257.     llectum  terminated  in  the  urethra. 

Sixth  Species.     Case  CLXXXII.,  p.  265.     Rectum  terminated  in  the 

vagina.     Sixth  Species. 
Schlagintweit,  Wilh  Aug  Joseph,  Case  CCLXXL,  p.  317.     Imperforate 

anus  and  rectum.     Third  Species. 
Schleiss,  Von,  Case  XC,  p.  189.    Imperforate  rectum  above  a  normal  anus. 

Fourth  Species. 
Shultz,  Case  XLVIII.,  p.  151.     Imperforate  anus   and   rectum.      Third 

Species. 
Scultetus,  Joannes,  Case  IV.,  p.  70.     Abnormal  contraction  of  the  anus. 

First  Species. 
Seaverns,  Case  X.,  p.  72.    Preternatural  narrowing  of  the  anus.     First 

Species. 
Serrand,  De  St.  Malo,  Case  CCLXIIL,  p.  315.     Imperforate  rectum  above 

a  normal  anus.     Fourth  Species. 
Shipman,  A.  B.,  Case  XXIX.,  p.  124.    Imperforate  anus  and  rectum.    Third 

Species. 
Smellie,  William,  Case  LXVIII.,  p.  168.     Imperforate  rectum  above  a 

normal  anus.     Fourth  Species. 
Smith,  Ashbell,  Case  CC,  p.  272.     Rectum  terminated   in    the  vagina. 

Sixth  Species. 
Smith,  J.  A.,  Case  CXLII.,  p.  247.     Rectum  terminated  in  the  bladder. 

Sixth  Species. 
Smith,  W.  G.,  Case  XLIV.,  p.  144.    Imperforate  anus  and  rectum.     Third 

Species. 


3G-i  INDhX   TO    ILLUSTRATIVE    CASES. 

Sommering,  Samuel  Tliom,  Case  CXL.,  p.  257.     Rectum  terminated  in  the 

urethra.     Sixth  Species. 
South,  J.  F.,  Case  CVI.,  p.  208.     Imperforate   anus,  with   an   abnormal 

opening  near  the  scrotum.     Fifth  Species. 
Steel,  John  H.,  Case  CXXXIX.,  p.  245.     Rectum  terminated  in  the  neck 

of  the  bladder.      Sixth  Species. 
Surgeon  of  Brest,  Case  CCLXV.,  p.  315.     Imperforate  anus  and  rectum. 

Third  Species. 
Surgeon  of  Lyons,  Case  CCLXIV.,  p.  315.     Imperforate  anus  and  rectum. 

Third  Species. 
Svvitzer,  Erico,  Case  CCII.,  p.  274.     Rectum  terminated  in  the  vagina. 

Sixth  Species. 

(T.) 

Textor,  K.,  Case  CCLXX.,  p.  317.     Imperforate  anus  and  rectum.     Third 

Species. 
Townsend,  Case  IX.,  p.  72.     Abnormal  narrowing  of  the  anal  orifice.    First 

Species. 
Trioen,   Cornel,   Case    LXVII.,   p.    108.      Imperforate    rectum    above  a 

normal  anus.     Fourth  Species. 

Vallesnieri,  Ant,  Case  CCXXI.,  p.  282.     The  uterus  terminated  in  the 

rectum.     Seventh  Species. 
Van  Meeckren,  Jobi  a,  vide  case,  p.  87. 
Van  Swieten,  Ger  F.  B.,  Case  CLXXVI.,  p.  264.     Rectum  terminated  in 

the  vagina.     Sixth  Species. 
Velpeau,  Alf  A.  L.  M.,  Case  CXX.,  p.  218.     Imperforate  anus,  with  an 

abnormal  opening  in  the  fourchette.     Fifth  Species.    Cases  CXL VII. — 

CXLVIIL,  p.  254.     Rectum  terminated  in  the  bladder.    Sixth  Species. 

Cases  CLXVIIL— CLXIX.— CLXX.,  p.  260.     Rectum  terminated  in 

the  urethra.     Sixth  Species. 


INDEX   TO    ILLUSTRATIVE   CASES.  305 

Vuisiii,  F.,  Caac  CCLYIU,,  p.  3K').     linpcrruratc  aims  and  icctiiiii.     Tliird 

Species.     Case  CCLX.,  p.  314.    Ilectum  and  colon  ))i»tli  absent.    Nintli 

Species. 
Voilleniici-,  Case  LXXXIIT.,  p.  183.     Imperforate  rectum  above  a  normal 

anus.     Fourth  Species. 
Vollgnad,   Case   CXXX.,   p.   237.     Rectum   terminated   in   the   bhicUlcr. 

Sixth  Species. 

(W.) 

Wagner,  Peter  Christopher,  Case  LXIV.,  p.  167.     Imperforate   rectum 

above  a  normal  anus.     Fourth  Species. 
AVaters,  Case  XLIIL,  p.  143.      Imperforate  anus  and   rectum.      Third 

Species. 
Wandermonde,  Case  CLXXXVII.,  p.  2G6.   Rectum  terminated  in  the  vagina. 

Sixth  Species. 
Wayte,  John,  Case  LXXIV.,  p.  17G.     Imperforate  rectum  above  a  normal 

anus.     Fourth  Species. 
Willaume,  Case  CLXIII.,  p.  258.     Rectum   terminated   in  the  urethra. 

Sixth  Species. 
"Williams,  Case   CLXVI.,  p.  258.     Rectum  terminated   in   the   urethra. 

Sixth  Species. 
Wolf,  C.  F.,  Case  LIX.,  p.  156.     Imperforate  anus  and  rectum.     Third 

Species. 
Wreisberg,  Henry  Aug.,  Case  CXXXIV.,  p.  239.     Rectum  terminated  in 

the  bladder.     Sixth  Species. 

t 

(Y.) 

York,  J.  H ,  Case  CLXXI.,  p.  260.     Rectum  terminated  in  the  urethra. 
Sixth  Species. 

(Z.) 

Zacutus,  Lusitanus,  Case  CLV.,  p.  257.     Rectum  terminated  in  the  urethra. 
Sixth  Species. 


INDEX. 


(A) 


Abdominal  Artificial  Anus 295 

General  Remarks  on 295 

History  of  the  Operation  for 304 

Littre's  Operation  for 309 

Pillore's  Operation  for 323 

Callisen's  Operation  for 324 

Amussat's  Operation  for 328 

Cases  of  Littre's  Operation  for. . .  311 
Cases  of  Pillore's  Operation  for. .  3'23 
Cases  of  Callisen's  Operation  for.  320 
Cases  of  Amussat's  Operation  for,  334 
Appreciation  of  Operation  for..  .  345 
Abnormal  or  Preternatural  Anus  —  200  290 

Abnormal  Position  of  the  Rectum 102 

Accoucheur,  The  Duty  of  the 38 

Etiology 4l 

MM.  Saiiit-Hiloire,  Eoux,  Serres, 

&c,onthe   42 

Anus  Abnormal,  Or  Preternatural,  200,  290 

Abdominal,  Artificial 295 

Coccygeal ,  Artificial 113 

Perina;al,  Artificial 96 

Absence  of 88 

Membranous,  Occlusion  of 75 

Congenital,  Malformations  of —    51 

Congenital,  Narrowing  of 61 

Syphilitic.  Contraction  of 62 

Arrested  Development,  Theory  of 43 

Various  authors  on  the 44 

Atresia  Ani — 37 

Atresia  Orificii  Ani 75 

Atresia  Ani  et  Intestini  Recti  88 

Atresia  Ani  Vesicalis,  Urethralis  and 

Vaginalis 201 

Auscultation  and  Percussion 90 

(B) 

Barton's   Operation   for   Atresia    Ani 

Vaginalis 234 

Bertin's  Proposition  to  open  the  Blad- 
der      238 

Bibliography 17 

Bigelow's  Objections   to    Proctoplasty 

and  Colotomy 92,  298 

Bougies,  The  Character  and  Use  of 64 

Bladder,  Rectum  Terminating  in  the..  225 
Cases  of 236 

[366] 


(C) 

PAGK. 

Caectfm.  Artificial  Anus  in 323 

Cases,  The  first  species  of 68 

The  second  Species  of 78 

The  third  species  of 123 

The  fourth  species  of 167 

The  fifth  species  of 206 

The  sixth  species  of 236 

The  seventh  species  of 280 

The  eighth  species  of 285 

The  ninth  species  of 292 

Recapitulation  of 294 

Littre's  operation  on 311 

Compendium  of 321 

Pillore's  Operation  on  323 

Callisen's  Operation  on 326 

Amussat's  Operation  on 334 

Classification,  Anal  and  Rectal  Malfor- 
mations of 52 

Coccygeal ,  Artificial  Anus 113 

Colon.  Absence  of 291 

Iliac ,  Artificial  Anus  in 309 

Lumbar ,  Artificial  Anus  in 324 

Colotomy 295 

Congenital  Malformations  of,  The  Rec- 
tum and  Anus 51 

Contraction  of  the  Anus 61 

Liability  of  Artiflc  ial  Anus  to. . .  108 

(D) 

Description  of  the  first  species  of  Mal- 
formation      61 

Of  the  second  species 75 

Of  the  third  species 88 

Of  the  fourth  species 163 

Of  the  fifth  species 200 

Of  the  sixth  species    225 

Of  the  seventh  species 278 

Of  the  eighth  species 283 

Of  the  ninth  species  290 

Dilatation,  In  Abnormal  Narrowing  of 
the  Anus 63 

Duty  of  Accoucheurs 38 

(E) 

Eighth  Species  of  Malformation 283 

Description  of 283 

1  reatment  of 284 

Cases  of 285 


INDEX. 


3GT 


PAOB. 

Elevations,  Or  Excrescences  of  the  Skin 
in  Anal  Region 00 

(F) 

Fifth  Species  of  Malformation 200 

Description   of 200 

Treatment  of 2o:i 

Cases  of '-00 

First  Species  of  Malformation  61 

Description  of 61 

Treatment  of 63 

Cases  of 6S 

Fourth  .Species  of  JIalformation 162 

Description  of 162 

Prognosis  of 165 

Treatment  of 165 

Cases  of 107 

(G) 

General  Remarks  on  Anal  and  Rectal 

Malformations 37 

On  Abdominal  Artificial  Anus. . .  295 

General  Symptoms 54 

Gross's  Objections  to  Colotomy 298 

(H) 

History  of  the  Operation  of  Abdominal 

Artificial  Anus 304 

The  Development  of  the  Rectum 
and  Auus 49 

(I) 

Iliac  Artificial  Anus 309 

Imperforate  Anus 75 

Rectum 162 

Index  to  Illustrative  Cases 349 

Incision  Circular,  Levret  on  77 

Incisions  in  Proctoplasty 99 

Form  of 99 

Infant  Pelvis,  Average  DimeHsions  of. .     98 

Deep  Incisions  in 98 

Contractions  of 284 

Intrauterine  Disease,  A  Cause  of  Malfor- 
mations     44 

Introduction 17 

Introduction  of  the  Sound  in  the  Ure- 
thra and  Vagina 99 

(L) 

Liability  to  Closure  of  Artificial  Anus.  108 
Lumbar  Artificial  Anus 324 

(M) 

Malformations ,  Anal  and  Rectal 37 

General  Remarks  on 37 

Terms  used  to  designate     37 

Etiology  of      41 

Anatomy  and  Pathology  of 46 

Classification  of 52 

General  Symptoms  of 54 

Prognosis  of 57 

Muscles   Sphincter  Ani 100 

Tlie  presence  and  absence  of      ...  100 
Different  opinion  of  autliorson..   101 

Maternal  Imagination,  as  a  cause  of  de- 
formities       41 


(N) 

Ninth  Species  of  Malformation 290 

Description  of 2.*0 

Treatment  of 291 

Casesof 292 

(O) 

Operation    for    Abdominal    Artificial 

Auus 295 

1  he  Process  of  Littre 309 

The  Process  of  Pillore 323 

Tlie  Process  of  Callisen 3'24 

The  Process  of  Amussat 3'28 

Operation  for  Perinicai  Artificial  Anus.  103 

Ordinary  method  of 105 

Amussat 's  metliod  of ll'i 

Hells  metliod  of 95 

Hutcliison's  method  of 120 

Roux'  method  of 258 

Friedbergs  metliod  Of  203 

Operation  for  Coccygeal  Artificial  Anus  1 13 

(P) 

Pathognomonic  Sign,  How  obtained..     52 
Pelvis,  Infant's,  Admeasurements  of. .     98 

Deep  incisions  in 98 

Perinaeal  Artificial  Anus 96 

PeriuEeal  Puncture 118 

The  common  method  of  perform- 
ing it 119 

The  author's  objections  to  it 119 

Hutchisons  modification  of  it 120 

Dieffenbach's  modification  of  it..  1'20 
Perinaeal  Raphe,  Continuance  and  Pro- 
minence of 88 

Physical  Exploration 89 

Physical  Signs 127 

Pipe-like  Prolongations  of  the  Rectum.  200 
Preternatural  Anus,  A  mere  Faeal  Fis- 
tula   295 

Primary  Cause  of  Malformations,  not 

known 43 

Prognosis,  General 57 

Of  the  third  species 91 

Of  the  fourth  species 165 

Of  the  fifth  species        201 

Of  the  sixth  species 230 

Proctoplasty , 96 

Longitudinal  incision  in 99 

Transverse  incision  in 99 

Crucial  incision  in 100 

T— incision  in 100 

Purging  New-born  Children ,  Pernicious 
Practice  of 38 

(R) 

Recapitulation  of  Cases 294 

Region,  Perinaeal,  Artificial  Anus  in...  96 

Coccygeal,  Artificial  Anus  in 113 

Iliac,  Artificial  Anus  in     309 

Lumbar,  Artificial  Anus  in 3'24 

Rectum,  Abnormal  Position  of 102 

Malformations  of 51 

Prolongations  of 200 

Membranous  occlusion  of 162 

Preternatural  terminations  of 51 

Preternatural      terminations     of 

other  organs  in 278 

Adventitious  Canals  of 200 

Obliteration  of 51 


368 


INDEX. 


PAGE. 

Rectum,  Absence  of 283 

Early  formation  of 49 

(S) 

Second  Species  of  Malformation 61 

Description  of 61 

Treatment  of 63 

Cases  of 68 

Seventh  Species  of  Malformation 278 

I  'escription  of 278 

Treatment  of 279 

Cases  of 280 

Sixth  Species  of  Malformation 225 

Description  of 225 

Physical  Signs  of 227 

Diagnosis  of 227 

Prognosis  of 227 

Treatment  of 231 

Casesof 236 

Speculum  Ani,  Use  of 164 

Sound,  Introduction  of 99 

Syphilitic  Contraction  of  the  Anus 62 

Synopsis  of  the  Anal  and  Rectal  Malfor- 
mations    51 

(T) 

Terms,  designating  the  Anal  and  Rectal 

Malformations  37 

Term,  Artificial  Anus  misapplied  295 

Its  strict  meaning  2^5 

Termination  of  the  Rectum,  Abnormal.  51 

In  the  bladder 225 

Intheurethra  226 


Termination  of  the  Rectum  in  the  vagina  226 

In  a  cloaca  in  the  perinseum 2'-5 

Third  Species  of  Malformation f8 

Description  of S8 

Physical  Exploration  of S9 

Diagnosis  of 89 

Prognosis  of 91 

Treatment  of 96 

Cases  of V:3 

Treatment  of  the  first  species 63 

Of  the  second  species 76 

Of  the  third  species f 6 

Of  the  fourth  species 165 

Of  the  fifth  species 202 

Of  the  sixth  species 231 

Of  the  seventh  species 279 

Of  the  eighth  species 284 

Of  the  ninth  species 291 

(U) 

Ureters,  terminating  in  the  Rectum 278 

Cases  of 280 

Urethra,  Rectum  terminating  in  the ....  226 

Cases  of 25(5 

Uterus,  terminating  in  the  Rectum 279 

Case  of 282 

(V) 

Vagina,  terminating  in  the  Rectum 278 

Cases  of 2S0 

Vagina,  Rectum  terminating  in  the '^26 

Cases  of 2  4 


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